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Part I
General Considerations
History ofInterventional Radiology
S.H.Chandrashekhara, PrinceDas, andRichaGauba
1
Key Messages
1. Intervention radiology has made tremendous advancements in the past decade due to less invasive procedures
leading to early recovery of the patients.
2. In 1953, Sven Ivar Seldinger described the ingenious
method of vascular access.
3. Interventional radiology revolutionized after the development of vascular catheterization and angiographic
techniques by Charles Dotter.
4. Alexander Margulis coined the term “interventional
radiology.”
5. The angiography technique was rst developed in 1927
by Egas Moniz.
6. Forssmann was awarded the Nobel Prize in 1956 for the
rst human cardiac catheterization. F.Mason Sones and
his associates performed the rst selective coronary
angiography in 1958.
7. In 1977, Andreas Gruentzig, father of coronary angioplasty, performed the rst coronary angioplasty (PTCA).
8. The rst human implantation of a self-expanding stent
was done in 1986 by Richard Schatz and further in 1987
by Julio Palmaz.
9. Ulrich Sigwart and Jacques Puel implanted the rst coronary stents in 1986 in Switzerland and in France,
respectively.
10. Goetz Richter and others performed the rst clinical
TIPS procedure with stents in January 1988 at Freiburg,
Germany.
S. H. Chandrashekhara (*)
Department of Radiodiagnosis and Interventional Radiology,
IRCH, All India Institute of Medical Sciences, Delhi, India
P. Das · R. Gauba
Department of Radiology, National Cancer Institute, Jhajjar, All
India Institute of Medical Sciences, Delhi, India
1.1 Introduction
Interventional radiology (IR) can diagnose and treat various
conditions by utilizing imaging guidance and minimally
invasive techniques. It offers less invasive alternatives to traditional surgical procedures. In this chapter, we will discuss
the history of interventional radiology, highlighting the key
milestones, advancements, and the impact it has had on
patient care. The rst arteriograms were successfully performed in 1923. Traditionally, “angiography” was considered to be interventional radiology. Initially, angiographers
did not manage the patients [1]. The evolution from diagnostic angiography to intervention radiology was possible due to
the expertise and skills of many angiographers. Interventional
radiologists are now expected to admit the patients, monitor
them both pre- and post-procedures, and also see patients in
clinical settings outside the hospital for management issues.
1.2 Early Beginnings
In 1953, Sven Ivar Seldinger described the process of introducing a catheter into the vascular system with the help of
needle access. These techniques became more rened with
time. Catheterization also became increasingly popular in
the United States in the late 1950s and early 1960s, and by
the mid-1960s, angiography became an established diagnostic medical specialty [2]. Charles Theodore Dotter is known
as the “Father of interventional radiology” for his tremendous contribution to the eld [3]. On June 19, 1963, Dotter
rst ofcially spoke about his work at the Czechoslovak
Radiological Congress in Karlovy Vary. During his presentation, he talked about catheter biopsy, occlusion catheterization, controlled exit catheterization, and the rationale of
catheter endarterectomy. The whole conference hall with
more than 300 attendees applauded Dr. Charles with a standing ovation [4].
On 16 January 1964, Dotter and his trainee, Melvin
Judkins, performed percutaneous transluminal angioplasty
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_1
3
4
S. H. Chandrashekhara et al.
for the rst time on an 82-year-old lady with severe left foot
pain. She was suffering from a non-healing foot ulcer and
gangrenous toes, but she refused the amputation that was
recommended to her by doctors. Dotter was consulted and
asked to see her because the patient refused surgery. The
patient had a short segment stenosis of the supercial femoral artery, which could have been treated by percutaneous
“dilating” catheters. Within minutes of the procedure, the
patient’s foot became warm and hyperemic, and the ulcer
soon healed [3]. Thereafter, Dotter published this showing
the treatment of supercial femoral artery stenosis with
serial dilators introduced using Seldinger’s method in 1964
[2].
After this, Dotter reduced the size of coaxial dilatation
catheters to 8F and 12F and improved the taper of their tips.
Initially, the technique was called “percutaneous transfemoral
catheter dilatation,” but later it was changed to “percutaneous transluminal angioplasty” (PTA) [4]. In the mid-1960s,
PTA was performed by Werner Porstmann from Berlin, and
his rst experience was published in 1967. Later on, the technique was accepted by many European angiographers [4].
Alexander Margulis coined the term “interventional radiology” in March 1967 [4]. He dened interventional radiology
as “manipulative procedures controlled and followed under
uoroscopic guidance that may be predominantly therapeutic or primarily diagnostic.” In his editorial, he also set
requirements for its performance [4].
very well [4, 7]. Nitinol stents were introduced in 1983 by
Dotter and colleagues, and Cragg and colleagues simultaneously published their results. Subsequently, the Gianturco Z
stent, Palmaz stent, and Wall stent were introduced in 1985
[4, 8]. The rst human implantation of a self-expanding stent
was done in 1986 by Sigwart and later in 1987 by Palmaz.
Stainless-steel wire was woven into a crisscrossed tubular
pattern followed by electropolishing by Palmaz under a lowpower microscope to make his original balloon-expandable
stent [8, 9].
1.5 Coronary Angiography
Cardiac catheterization and angiocardiography were rst
attempted by Forsmann in 1929. In 1941, Cournand demonstrated that cardiac catheterization was a safe method in
humans. The rst balloon angioplasty was performed in
1977 by Gruentzig [10]. An article on “occlusion aortography” was published by Dotter in July 1958, in which he
described his canine experiments. Detailed images of the
coronary vasculature were generated by occlusion aortography. Judkins further developed an improved set of catheters
for the coronary ostia, regardless of the aortic structure [3].
1.6 Acute Gastrointestinal Bleeding
1.3 Catheter-Directed Thrombolysis
The technique of catheter-directed thrombolysis was introduced by Dotter in 1972. Because of the large size of diagnostic coronary catheters (8F) and coaxial dilation catheters
(12F), there were complications during the procedures, such
as thrombosis at the catheter tip or dilatation sites. Catheterdirected thrombolysis initially originated as a treatment for
these complications [5, 6].
1.4 Stents
The Swiss surgeon Dierk Maass, along with other interventional radiologists, in the early and mid-1980s, introduced a
variety of expandable metallic stents. These were either selfexpanding or balloon-expandable stents made primarily of
stainless-steel alloys or thermal memory stents made of nitinol, an alloy of nickel and titanium. Self-expandable spiral
coils and double-helix stents were introduced in 1982 by
Maass and were used for relieving inferior vena cava obstructions and occasionally in aortic dissections. However,
because of the large-size introducer sheaths, arterial cutdown
was required, and hence, these devices were not accepted
Angiographic diagnosis and treatment of acute gastrointestinal bleeding was pioneered by Stanley Baum and Moreye
Nusbaum in the 1960s [11]. A continuous infusion of lowdose vasopressin was started for control of variceal bleeding
[12]. Isobutyl 2-cyanoacrylate and gel foam mixed with
sodium tetradecyl sulfate are quite effective as embolic
agents in controlling acute bleeding. The transhepatic portal
vein approach was also developed for selective catheterization and embolization of varices. Anders Lunderquist performed transhepatic variceal embolization for the rst time
in 1974 [13].
1.7 Transjugular Intrahepatic Portosystemic Shunt
Experiments on canines were carried out for developing the
technique of transhepatic portosystemic shunt (TIPSS) in the
late 1960s at the University of California, Los Angeles, by
Rosch [14]. The rst clinical TIPSS creation was done in the
early 1980s by Ronald Colapinto and colleagues by continuous 12-h balloon dilation in the liver parenchyma. In the
mid-1980s, Palmaz further evolved this technique by introducing balloon-expandable stents to keep the TIPSS open.
The rst clinical TIPS procedure using a Palmaz stent was
1 History ofInterventional Radiology
5
performed in January 1988 at Freiburg, Germany, by Goetz
Richter and associates. TIPSS, a minimally invasive technique for the management of portal hypertension, has now
become popular worldwide [15].
1.8 Conclusion
Interventional radiology has come a long way since its inception, transforming the way many medical conditions are
diagnosed and treated. It provides less invasive alternatives
to conventional surgical treatment with shorter hospital stays
and improved patient outcomes. The eld continues to evolve
with advancements in technology, collaboration with other
specialties, and a patient-centered approach, paving the way
for further innovation and progress in interventional
radiology.
References
1. Tai E, Graham T, Wong J, Mujoomdar A. Interventional radiology’s evolution into a clinically based specialty. Can Assoc Radiol
J. 2021;72(3):341–2.
2. Murphy TP, Soares GM. The evolution of interventional radiology. In: Seminars in interventional radiology, vol. 22, no. 01.
Copyright© 2005 by Thieme Medical Publishers; 2005. p.6–9.
3. Payne MM. Charles Theodore Dotter: the father of intervention.
Tex Heart Inst J. 2001;28(1):28.
4. Rösch J, Keller FS, Kaufman JA.The birth, early years, and future of
interventional radiology. J Vasc Interv Radiol. 2003;14(7):841–53.
5. Katzen BT, van Breda A.Low dose streptokinase in the treatment
of arterial occlusions. AJR Am J Roentgenol. 1981;136:1171–8.
6. Becker GJ, Rabe FE, Richmond BD, etal. Low-dose brinolytic
therapy: results and new concepts. Radiology. 1983;148:663–70.
7. Borhani S, Hassanajili S, Ahmadi Tafti SH, Rabbani
S.Cardiovascular stents: overview, evolution, and next generation.
Prog Biomater. 2018;7:175–205.
8. Wright KC, Wallace S, Charnsangavej C, Carrasco CH, Gianturco
C. Percutaneous endovascular stents: an experimental evaluation.
Radiology. 1985;156:69–72.
9. Palmaz JC, Sibbitt RR, Reuter SR, Tio FO, Rice WJ.Expandable
intraluminal graft: a preliminary study. Radiology. 1985;156:73–7.
10. Wilms G, Baert AL. The history of angiography. J Belg Radiol.
1995;78(5):299–302.
11. Nusbaum M.Radiographic demonstration for unknown site of gastrointestinal bleeding. In: Surg Forum, vol. 14; 1963. p.374.
12. Baum S, Nusbaum M.The control of gastrointestinal hemorrhage
by selective mesenteric arterial infusion of vasopressin. Radiology.
1971;98(3):497–505.
13. Lunderquist A, Vang J.Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and
esophageal varices. N Engl J Med. 1974;291(13):646–9.
14. Rösch J, Hanafee W, Snow H, Barenfus M, Gray R.Transjugular
intrahepatic portacaval shunt an experimental work. Am J Surg.
1971;121(5):588–92.
15. Richter GM, Palmaz JC, Nöldge G, etal. Der transjuguläre intrahepatische portosystemiche stent shunt (TIPSS). Radiologe.
1989;29:408–11.
Patient Preparation inInterventional
Radiology
VishnuPrasadPulappadi andS.H.Chandrashekhara
2
Key Messages
1. Proper pre-procedure evaluation is necessary before performing any image-guided intervention.
2. Elaborate history-taking and clinical examination constitute the rst step in patient evaluation.
3. Imaging studies must be reviewed to ascertain the necessity and feasibility of image-guided intervention.
4. In patients with a high risk of bleeding, coagulation
parameters should be assessed, and antiplatelet and anticoagulant agents should be withheld before the
procedure.
5. Appropriate prophylactic antibiotic is essential in procedures with a high risk of infection.
2.1 Introduction
A thorough evaluation of the patient is essential in identifying the patient as a candidate for an image-guided intervention. The planned intervention should be benecial to the
patient, and the expected benets should outweigh the risks
associated with it. History taking, examination, and investigations including imaging help in reaching a denitive diagnosis, following which the appropriate treatment can be
planned for the patient. In addition, certain screening tests
and investigations may be required to assess the risk associated with the procedure. Regardless of the disease and the
type of intervention, pre-procedure evaluation is one of the
most important factors that determines the success of the
procedure.
2.2 History-Taking
Routine history-taking is the rst step in patient evaluation.
The chief complaints of the patient should be assessed along
with their durations. Ascertaining the severity of symptoms
and its effect on the quality of life of the patient helps in
deciding the appropriate treatment. In disorders that are not
rapidly progressive and are not associated with unpredictable
life-threatening complications, the choice between medical
management and endovascular intervention depends upon
whether the patient is symptomatic and whether the symptoms are lifestyle-limiting.
Associated co-morbidities may adversely affect the treatment outcome and increase the risk of complications. In
patients with multiple co-existing illnesses, the exact cause
of symptoms must be ascertained before proceeding with the
treatment.
History of substance use such as alcohol and smoking
needs to be assessed. Patients who continue to smoke have
worse outcomes after angioplasty as compared to those who
quit smoking [1]. The presence of active COVID-19 infection increases the risk of failure after angioplasty or stenting
as it is associated with an increased risk of thrombosis [2].
Any history of allergy to iodinated contrast agents or any of
the drugs that are planned to be administered during the procedure should be obtained. In women of the reproductive age
group, menstrual history should be obtained to avoid radiation exposure to the embryo during early pregnancy.
2.3 Examination ofthePatient
The interventional radiologist who will perform the procedure should examine the patient by himself. The general condition and performance status of the patient should be
V. P. Pulappadi
Kovai Medical Center and Hospital, Coimbatore, India
S. H. Chandrashekhara (
Department of Radiodiagnosis and Interventional Radiology,
IRCH, All India Institute of Medical Sciences, Delhi, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_2
*)
assessed as poor performance status is associated with poor
procedure outcomes. Vital parameters of the patient, including the heart rate, blood pressure, oxygen saturation, and
respiratory rate, should be assessed during the initial presen-
7
8
V. P. Pulappadi and S. H. Chandrashekhara
tation and also before the procedure. Pallor should be looked
for, especially in patients presenting with excessive bleeding.
Icterus should be checked in patients with liver disease. The
presence of pedal edema should raise the suspicion of cardiac or renal dysfunction and must be investigated prior to
the procedure.
After ascertaining the general condition of the patient,
further examination should be directed at the specic disease
the patient is suffering from. For example, in patients with
suspected vascular malformation, the swelling should be
assessed for overlying skin discoloration or change in size
with the Valsalva maneuver, indicative of a venous
malformation, or warmth and pulsations over the swelling,
indicative of an arteriovenous malformation. In patients with
peripheral vascular disease, the affected limb should be
examined for gangrene, ulcers, loss of hair, motor movements, sensations, and cold temperature. Proximal and distal
pulses should be assessed to ascertain the level of stenosis or
occlusion.
A detailed pre-procedure neurological examination is to
be done before any neurovascular intervention. It not only
helps in deciding whether the intervention is indicated in the
patient or not, but also forms a baseline with which posttreatment ndings can be compared. The motor and sensory
examination must be performed in all limbs. Cerebellar signs
should be looked for in patients with lesions involving the
posterior fossa.
The pulse in the artery that is planned to be punctured for
access should be assessed. A good-quality pulse indicates
that the artery can be safely punctured. In case the pulse is
not palpable, ultrasound assistance becomes necessary for
the puncture. The status of distal pulses beyond the puncture
site should be assessed wherever applicable. Loss of distal
pulse after the procedure indicates distal embolization of clot
that may have formed in the access sheath.
2.4 Pre-procedure Imaging
The type of imaging modality that needs to be used for preprocedure evaluation depends upon the pathology and the
organ that is affected. Recent imaging is essential in ascertaining the disease status prior to the intervention.
Screening ultrasound scan should be done prior to
ultrasound- guided biopsy or drainage procedures, to conrm
the visibility of the lesion on ultrasound scan and whether it
is accessible for biopsy or drainage. For CT or MRI guided
procedures, the recent scan must be reviewed to conrm the
feasibility of biopsy or drainage. In transhepatic interventions, it is important to assess the liver size and morphology,
presence of perihepatic uid, and biliary dilation to ascertain
the risk of bleeding and infection during the procedure. Preprocedure CT angiography is helpful in embolization proce-
dures involving the bronchial artery, hepatic artery, renal
arteries, and mesenteric arteries to ascertain the arterial anatomy. Pre-procedure non-contrast CT brain may be obtained
for procedures that may result in intracranial hemorrhage,
such as embolization of arteriovenous malformation and
aneurysm coiling. This comes in handy for comparison with
the post-procedure scan for any new bleed that occurred during the procedure.
2.5 Pre-procedure Investigations
Routine pre-procedure investigations are not indicated for
healthy individuals undergoing minor procedures. However,
if a major intervention is being planned, where excessive
blood loss may occur, a complete blood count may be
obtained prior to the procedure [3]. Further pre-procedure
investigations would depend upon the type of intervention
that is being planned and on the patient’s comorbidities.
In patients with a history of renal dysfunction, a renal
function test has to be obtained. In patients with liver disease
or obstructive jaundice, a liver function test needs to be
obtained to ascertain the necessity of the procedure, such as
in percutaneous transhepatic biliary drainage, or to assess
risk associated with the procedure, such as in transjugular
intrahepatic portosystemic shunt. Total and differential leukocyte counts and procalcitonin levels should be obtained in
patients with suspected infection. In patients with proven
sepsis, endovascular interventions are best performed after a
course of antibiotics and the blood cultures become negative.
In patients with suspected or conrmed vasculitis, inammatory markers must be obtained to rule out active disease prior
to endovascular management.
Cardiovascular adverse events associated with contrast
injection are more common in patients with underlying cardiac disease due to reduced tolerability to the osmotic load
and negative chronotropic effects of iodinated contrast
agents. Therefore, any history suggestive of cardiac disease
must be elicited. Further evaluation using electrocardiogram
and echocardiogram may be performed if clinically
indicated.
2.6 Assessment ofRisk Associated
withIodinated Contrast Use
Iodinated contrast agents may result in contrast-induced
nephropathy, especially in patients who have pre-existing
renal insufciency. The risk of contrast induced nephropathy
is high in patients with eGFR less than 30ml/min/1.73m2.
Therefore, eGFR estimation prior to the procedure is recommended in certain patients who have a high risk of renal
insufciency [4]. Such patients include:
2 Patient Preparation inInterventional Radiology
9
• Personal history of renal disease
– Known chronic kidney disease
– Remote history of acute kidney injury
– Dialysis
– Renal surgery
– Renal ablation
– Albuminuria
• History of diabetes mellitus (optional)
• Metformin or metformin-containing drug combinations
Serum creatinine estimation is not required for proce-
dures that don’t involve intravascular contrast injection.
Volume expansion using intravenous uids is indicated in
patients with eGFR less than 30ml/min/1.72 m2 to reduce
the risk of contrast-induced nephropathy. It can also be considered in patients with borderline eGFR of 30–44 ml/
min/1.72m2 who have other risk factors for the development
of contrast-induced nephropathy. 0.9% isotonic normal
saline is the preferred intravenous uid and can be given at
1–3ml/kg/h or as 500ml volume before and after the procedure. It can be started 1h prior to the procedure and continued for 3–12h after the procedure [4]. Risk factors for uid
overload such as congestive heart failure should be ruled out
prior to volume expansion.
Other agents such as sodium bicarbonate, N-acetyl cysteine, and diuretics have not been shown to be effective in
reducing the likelihood of contrast-induced nephropathy [4].
Premedication is given to reduce the risk of adverse
effects associated with contrast injection. It is indicated in
patients who have a prior allergic-like or unknown-type contrast reaction to iodinated contrast agents. Use of premedication routinely in all cases or in patients who have a history of
asthma or allergy to other substances including gadoliniumbased contrast agents, drugs, and food items is not necessary.
The recommended regimens for oral premedication are as
follows:
• 50mg prednisone by mouth at 13h, 7h, and 1h before
contrast medium administration, plus 50mg diphenhydr-
amine intravenously, intramuscularly, or by mouth 1 h
before contrast medium administration
• 32mg methylprednisolone by mouth 12h and 2h before
contrast medium administration. 50mg diphenhydramine
may be added as in prednisone-based regimen
Accelerated intravenous premedication is indicated in
high-risk patients in whom the procedure cannot be delayed
till the 12 or 13-h oral regimen is completed. The recommended accelerated regimens are as follows:
• Methylprednisolone sodium succinate 40mg IV or hydro-
cortisone sodium succinate 200mg IV immediately, and
then every 4h until contrast medium administration, plus
diphenhydramine 50mg IV 1 h before contrast medium
administration. This regimen usually is 4–5 h in
duration.
• Dexamethasone sodium sulfate 7.5mg IV immediately,
and then every 4h until contrast medium administration,
plus diphenhydramine 50 mg IV 1 h before contrast
medium administration. This regimen may be useful in
patients with an allergy to methylprednisolone and is also
usually 4–5h in duration.
• Methylprednisolone sodium succinate 40mg IV or hydrocortisone sodium succinate 200mg IV, plus diphenhydramine 50 mg IV, each 1 h before contrast medium
administration. This regimen, and all other regimens with
a duration of less than 4–5h, has no evidence of efcacy.
It may be considered in emergent situations when there
are no alternatives.
Premedication regimens that are less than 4h in duration
are not shown to be effective. Therefore, if the procedure is
to be done on an emergency basis in patients who are at high
risk of contrast reaction, the procedure can be performed
without premedication but with all necessary precautions for
resuscitation of the patient in case of a contrast reaction [4].
Keeping the patient in a fasting state on the day of the
procedure is sometimes practiced to reduce the likelihood of
vomiting and aspiration. However, aspiration pneumonia
rarely occurs as a result of intravascular contrast administration. On the other hand, fasting may cause discomfort to the
patients and result in hypoglycemia in diabetic patients.
Therefore, fasting is not routinely required for procedures
involving intravascular iodinated contrast administration,
unless the procedure is planned to be performed under general anesthesia [4].
2.7 Assessment ofBleeding Risk
Society of Interventional Radiology (SIR) has classied
image-guided interventions into low- or high-risk ones
depending upon the risk of bleeding [5]. Only those procedures that have a high risk of bleeding require routine testing
for dysfunctional coagulation prior to the procedure. In general, all procedures that are performed on supercial body
parts and blood vessels have low bleeding risk as the bleeding can be stopped by manual compression. Procedures that
involve deep organs are considered high risk as the bleeding
into the body cavity is not amenable to manual compression
and hence cannot be immediately stopped. Detailed discussion on periprocedural bleeding risk and management of
antithrombotic agents is given in the chapter on bleeding and
thrombotic risk.
10
V. P. Pulappadi and S. H. Chandrashekhara
2.8 Informed Consent
Written informed consent is to be obtained from all patients
prior to performing any image-guided intervention. The
patient should be thoroughly counseled regarding his/her illness. All available treatment options for the particular condition have to be discussed with the patient. The risks and
success rate associated with the procedure should be conveyed to the patient. Information regarding the natural history of the disease, if left untreated, should also be conveyed.
This helps the patient in making an informed decision on
whether to undergo the procedure or not. The consent is to be
taken by the primary treating physician who will perform the
procedure on the patient. If the patient is aged less than
18years or is not able to give consent due to mental illness
or unconscious state, consent should be taken from the
guardian or close relative. All expected complications, both
minor and major ones, should be mentioned in the consent
form.
2.9 Anesthesia andSedation
Most of the endovascular and non-vascular image-guided
interventions can be performed under local anesthesia or
conscious sedation. General anesthesia may be required in
certain situations such as:
• Pediatric population
• Uncooperative or anxious patients
• Painful procedures such as tumor ablation and
sclerotherapy
• High-risk procedures such as embolization of cerebral
arteriovenous malformation and intracranial aneurysm
coiling where strict immobilization is necessary to prevent the risk of intracranial bleeding
• Basilar artery interventions where tight hemodynamic
control is desired
• Pulmonary artery interventions due to high risk of
arrhythmias
Patients should be kept nil per oral if general anesthesia is
being planned. As per the practice guidelines of the American
Society of Anaesthesiologists [6],
• Clear liquids may be given up to 2 h prior to the
procedure
• Breast milk up to 4h prior to the procedure
• Solid food and nonhuman milk up to 6 h prior to the
procedure
Pre-anesthetic check-up should be obtained if general
anesthesia is anticipated. Anesthesiologist backup should
also be sought in patients with chronic pulmonary diseases
or cardiac dysfunction as they have a high risk of complications if contrast reaction or other procedure-related adverse
events occur.
2.10 Part Preparation
Removal of hair around the site of puncture is to be done if it
interferes with the puncture. Hair removal has not shown to
denitely reduce the risk of infection. On the other hand, it
may increase the risk of infection as a result of micro-trauma
induced on the skin. If hair removal is being done, it is to be
done using clippers to avoid micro-trauma to the skin and
should be performed just prior to the procedure to reduce the
amount of bacterial load in the skin at the time of puncture [7].
2.11 Antibiotic Prophylaxis
Endovascular and non-vascular procedures are associated
with the risk of inoculation of bacteria into the bloodstream,
from the skin, mucosal surface, or infected cavities. This can
lead to clinically evident infection in a small number of
cases. Antibiotic prophylaxis prior to the procedure helps to
clear the bacteria that may enter the bloodstream during the
procedure. Prophylactic antibiotic, if given, has to be administered 1h prior to the puncture, and a repeat dose is indicated if the procedure starts more than 2h after the rst dose.
This is to ensure optimum antibiotic concentration within the
blood at the time of puncture. Factors that are associated
with high rates of infection are the long duration of the procedure, multiple catheterizations at the same site, difcult
arterial access, and post-procedure maintenance of arterial
sheaths, such as in catheter-directed thrombolysis. Bare stent
placement doesn’t require routine antibiotic coverage unless
the patient is immunosuppressed, while stent graft placement
needs to be done under antibiotic cover as the interstices of
the graft are difcult to sterilize completely. Prophylactic
antibiotics are also indicated in certain embolization procedures, such as uterine artery embolization or hepatic embolization, as the necrotic material created can get secondarily
infected by bacteria from the genital tract and biliary tract,
respectively. Similarly, it is safer to perform percutaneous
ablation of tumors under antibiotic cover to reduce the incidence of abscess formation in the necrotic tumor. Prophylactic
antibiotics are also indicated during percutaneous transhepatic biliary drainage and percutaneous nephrostomy as an
2 Patient Preparation inInterventional Radiology
11
Table 2.1 Antibiotic prophylaxis for various image guided interventions [8]
Procedure Antibiotic regimen
Stent graft placement Cefazolin 1g IV
Uterine artery embolization Cefazolin 1g IV
Hepatic embolization Cefazolin 1g IV+
Tunneled dialysis catheter Cefazolin 1g IV
Sclerotherapy of slow ow vascular
malformation
Transjugular intrahepatic
portosystemic shunt
Percutaneous transhepatic biliary
drainage
Percutaneous nephrostomy Ceftriaxone 1g IV
Tumor ablation Cefazolin 1g IV
Metronidazole 500mg IV
Cefazolin 1g IV
Ceftriaxone 1g IV
Ceftriaxone 1g IV
obstructed biliary system and pelvicalyceal system may harbor bacteria that may gain entry into the bloodstream during
these procedures. The prophylactic antibiotics indicated during various procedures are summarized in Table2.1 [8].
2.12 Antiplatelet Use Prior toAngioplasty
andStent Placement
Use of antiplatelet agents is essential in maintaining the vessel’s patency after angioplasty or stenting. Incidence of
restenosis is higher if antiplatelet agents are not used during
such procedures. Most commonly used drug combination is
aspirin and clopidogrel [9]. Aspirin is given as a loading dose
of 325mg, at least 3h prior to the procedure, in the form of
non-enteric coated tablets, followed by maintenance dose of
150mg once daily. The loading dose of clopidogrel is 600mg
if the procedure is planned to be performed within 24h and
300mg if the procedure is being performed after 24h. It is
followed by a maintenance dose of 150mg once daily. There
is a high incidence of resistance to clopidogrel in certain
patient populations, such as smokers, diabetics, and chronic
kidney disease, in which cases, it can be replaced with
ticagrelor [9]. Ticagrelor is given as a loading dose of 180mg
at least 1h prior to the procedure, followed by 90mg twice
daily.
References
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Image Guidance inInterventional
Radiology
SurabhiVyas andAnjanaRao
3
Key Messages
1. Interventional radiology encompasses both diagnostic
and therapeutic interventions using various imaging
modalities.
2. Interventional radiology can offer minimally invasive
alternatives to more complex surgical procedures that
warrant signicant morbidity and mortality.
3. A variety of radiation-using imaging modalities ranging
from uoroscopy, digital subtraction angiography, and
computed tomography are used.
4. Non-radiation modalities like ultrasonography and magnetic resonance imaging haves has the added advantage
of use in the pregnant and pediatric population.
5. Ultrasound uses an in-plane or out-of-plane approach for
needle visualization. Advances in ultrasonography techniques like needle guides, electromagnetic sensors, and
optical tracking aid in better needle placement.
6. Digital subtraction angiography and uoroscopy are
invaluable tools in angioplasty, venoplasty, and stenting
procedures.
7. Computed tomography has the added advantage of
cross-sectional capabilities and multiplanar reconstructions, which are especially relevant in procedures like
drainages and ablations, which require precise anatomical localization.
8. Magnetic resonance imaging with its superior soft tissue
contrast resolution has high sensitivity for liver, prostate,
breast, and bony pathologies and thus helps in biopsy
and ablative procedures.
9. It is imperative to ensure patient safety with minimum
radiation and radiofrequency energy deposition.
10. The use of iodine based and MRI contrast agents facilitates the diagnostic and interventional procedures.
S. Vyas (*) · A. Rao
Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, Delhi, India
3.1 Introduction
Interventional radiology (IR) refers to minimally invasive
diagnostic and therapeutic interventional procedures using
various imaging modalities ranging from ultrasonography,
uoroscopy, and computed tomography to digital subtraction
angiography and magnetic resonance imaging. Advances
over the last few decades have widened the scope of interventional radiology to provide advanced therapeutic procedures in various non-malignant and malignant conditions
[1]. With the availability of image guidance software and
robots, further renements in techniques have been achieved
with lesser operator dependence [2].
Recent advances in technology have led to the development of standard operating procedures regarding various
interventional procedures with special emphasis on the
reduction of radiation dose where feasible using the ALARA
(as low as reasonably achievable) principle.
3.2 Ultrasonography
Ultrasonography (USG) is the most widely used modality for
various interventional procedures (Fig.3.1). Its use ranges
from guidance for biopsy procedures and placement of various drainage catheters to guiding nerve blocks and gaining
vascular access [3].
3.2.1 Advantages
• USG is a real-time guidance modality. It allows real-time
visualization of the needle tip, so as to ensure appropriate
placement.
• It is a radiation free modality and thus can be safely used
in pregnancy and the pediatric population.
• USG machine is a portable equipment and can be used for
bedside procedures.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_3
13