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Fig. 7.5 (continued)
Fig. 7.6 Coronal CT of the abdomen and pelvis in a female, (a–c) ante-
rior to posterior. (a) Anterior section with both right and left lobes of the
liver identiable (see Fig.7.8 for more detail). The gallbladder is located
along the inferior aspect of the liver, and the stomach is adjacent to the
left hepatic lobe. The majority of the small and large bowel is present in
this plane. The femoral artery is the continuation of the external iliac
artery after exiting the pelvis under the inguinal ligament. (b) Section
through the femoral heads. Origins of the celiac artery and superior mesenteric artery are located in the central abdomen. The liver occupies the
right upper quadrant, and the stomach and spleen occupy the left upper
quadrant. (c) Posterior section through the liver, spleen, and kidneys.
Body of the anteroexed uterus lies superior to the bladder
92
Fig. 7.7 Supine abdominal
radiograph. Abdominal organs
are visible on radiography due
to the difference in density
between organ
(predominantly water) and the
surrounding fat. However, the
contrast is usually low
between these tissues, making
them sometimes difcult to
distinguish. The kidney and
psoas muscles are outlined by
adjacent fat. The bowel is
easy to identify when
air-lled, as is the case on this
radiograph
A. Donithan et al.
Fig. 7.8 Transverse grayscale ultrasound images of the liver. (a)
Inferior transverse section through the liver at the level of the portal
vein. Fluid (blood vessels) typically appears anechoic on ultrasound.
The inferior vena cava (IVC) is rightward, and the aorta is leftward of
the vertebral body. The right kidney is lateral to the IVC and inferior
and posterior to the liver. The main portal vein bifurcates into left and
right divisions at this level. (b) Superior transverse section through the
liver at the level of the IVC and hepatic veins
7 Introduction toCross-Sectional Imaging
93
Fig. 7.9 Couinaud liver segments I–VIII. Axial CT images (a–d) from
superior to inferior. Coronal CT images (e, f) with (f) anterior to (e).
The portal veins divide the superior segments from the inferior segments (dark line in (e)). (a) Line drawn down the middle hepatic vein
(MHV) in plane with the gallbladder fossa separates the left and right
hemiliver. The left hemiliver is comprised of segments II and III medially and segments IVa/b laterally that are separated by a line extrapolated from the IVC superiorly through the plane of the falciform
Fig. 7.10 Illustration of the Couinaud liver segments I–VIII. The
liver is divided from superior to inferior segments by the portal vein
(purple vessels). The liver is divided laterally by the hepatic veins
(blue vessels)
ligament (FL) (c, d, f). The right hemiliver is subdivided into segments
VIII and V anteriorly and segments VII and VI posteriorly with a line
extrapolated along the right hepatic vein. The caudate lobe (segment I)
is anteromedial to the IVC (b). Notice that the SMV is anterior and
lateral to the SMA (d). RHV, MHV, LHV, right, middle, and left hepatic
veins, respectively; IVC, inferior vena cava; Ao, aorta; LPV, left portal
vein; PV, main portal vein; SMV, superior mesenteric vein; SMA, superior mesenteric artery; FL, falciform ligament
The portal veins enter the hepatic parenchyma at the hilum
and separate the superior and inferior liver (Fig.7.8a). The
three hepatic veins “drape” over the superior aspect of the
liver and form a conuence with the IVC at the superior and
posterior aspect (see Fig. 7.8b). The middle hepatic vein
separates the liver into the right and left hemiliver, by a plane
drawn from the IVC superiorly to the gallbladder fossa inferiorly along the course of the middle hepatic vein. The right
hepatic vein separates the right hemiliver into medial (5 and
8) and lateral (6 and 7) segments. The left hepatic vein is not
used in the classical segmental schematic. Separating the left
hemiliver into lateral (4a and 4b) and medial (2 and 3)
segments is the falciform ligament with a plane drawn from
the conuence of the left and middle hepatic vein conuence. The caudate lobe is separated from the remaining liver
by the ligamentum venosum, having its own venous drainage
to the IVC (Figs.7.9 and 7.10).
The biliary system is best evaluated by MRI or direct
opacication with iodinated contrast agent under uoroscopy (percutaneous transhepatic cholangiogram (PTC)).
94
A. Donithan et al.
Fig. 7.11 Biliary anatomy. (a) MRI image showing normal duct anat-
omy. The right and left hepatic ducts (RHD and LHD, respectively) join
to form the common hepatic duct (CHD). This becomes the common
bile duct (CBD) downstream of the conuence with the cystic duct
(CD). The CBD and the pancreatic duct (PD) drain into the duodenum
at the ampulla of Vater (aV). Notice the appearance of multiple dark
However, ultrasound and CT can also detect when the bile
ducts are dilated. The bile ducts are adjacent to the portal
veins in the hepatic parenchyma, owing toward the hepatic
hilum as the right and left hepatic ducts, converging to
become the common hepatic duct, which joins the cystic
duct (from the gallbladder) to form the common bile duct
(CBD). The CBD usually joins with the main pancreatic
duct to empty into the second portion of the duodenum via
the ampulla of Vater (major papilla) (Fig.7.11). Several versions of recognized variant anatomy along this course have
been described with surgical implications.
Kidneys
The kidneys are located in the posterior retroperitoneum, on
each side of the spine. The superior aspect of the kidney lies
deep to the 11th and 12th ribs and consequently, the pleural
space and diaphragm. The kidney can move 2–3cm in the
superior-inferior direction with the respiratory cycle and also
move with bending of the spine. The right kidney is positioned slightly more inferior to the left kidney, due to the
presence of the liver occupying the space superior to it. The
inferior pole of the right kidney lies approximately a nger’s
width above the left iliac crest.
The renal hilum is on the anterior medial aspect of the
kidney (see Fig.7.5e) and is the location that the blood vessels and ureters enter and exit the parenchyma. In the hilum,
the renal vein is located anterior to the renal artery which is
anterior to the renal pelvis (the conuence of the urinary collecting system before becoming the ureter). The renal artery
splits into anterior and posterior division before entering the
round lling defects within the gallbladder (GB) signifying cholelithiasis. (b) Intraoperative cholangiogram from the same patient following
cholecystectomy (injections of contrast via the ligated cystic duct).
There are no lling defects within the CBD, indicating no evidence of
choledocholithiasis
renal hilum. The separate divisional arteries pass through the
hilum, along the medullary pyramid, and into the cortex
(Fig.7.12), sequentially becoming smaller in caliber. Along
the posterior lateral aspect of the kidney, there is an avascular
plane due to this termination of the anterior and posterior
division of the renal arteries. This is referred to as Brodel’s
avascular line. When percutaneously accessing the urinary
collecting system, it would be ideal to pass through this
plane; however, the location is variable and is not easily
identied. Despite this, it is usually safe and results in the
best catheter course to enter the posterior calyx from a posterolateral approach.
Ureters
The ureters are bromuscular urothelial lined tubes that transport urine from the kidneys to the urinary bladder. These retroperitoneal structures descend from the renal hilum along the
psoas muscles (see Fig. 7.5g), coursing anterior the external
iliac arteries, along the lateral pelvic sidewall just deep to the
peritoneal surface, and then enter the urinary bladder. The ureters have three sites of physiologic constriction that are potential
sites for obstruction by calculi: (1) at the junction between the
renal pelvis and the ureter, the ureteropelvic junction; (2) as the
ureter course over the iliac artery; and (3) at the junction of the
ureter and the urinary bladder, the ureterovesicular junction.
Bladder
The urinary bladder is a muscular hollow organ located in
the extraperitoneal space of the anterior pelvis (see
Figs.7.5h and 7.6b). It resides posterior to the pubic sym-
7 Introduction toCross-Sectional Imaging
Fig. 7.12 Longitudinal
grayscale ultrasound image of
the left kidney. The cortex is
less echogenic than the
adjacent perinephric fat. The
pyramids are more
hypoechoic than the cortex,
but should not be confused
with hydronephrosis, which
would be anechoic and have
mass effect on the renal
parenchyma. The renal sinus
fat is hyperechoic to the
kidney and surrounds the
vessels and urinary collecting
system in the hilum of the
kidney
Fig. 7.13 Transvaginal
ultrasound of the female
pelvis. Longitudinal view of a
normal uterus in the
proliferative phase of the
menstrual cycle, with an
anteverted anteexed position.
The endometrium is
hyperechoic relative to the
adjacent myometrium. The
isthmus is the narrowest part
of the uterus located between
the body and the cervix
95
Fig. 7.14 MRI of the female
pelvis. Sagittal T2-weighted
sequence of anteverted and
anteexed uterus. The
endometrium is hyperintense
(bright) relative to the
adjacent myometrium. The
rectum can be seen posterior
and the bladder anterior to the
uterus
physis and superior to the pelvic bones. The bladder can
move freely in the surrounding extraperitoneal fat. Only the
bladder dome is covered by a peritoneal lining. The vascular supply to the bladder is located posteriorly, leaving the
anterior surface open to percutaneous interventions. As the
bladder lls, it expands above the pubic symphysis, dis-
placing surrounding bowel superiorly and posteriorly.
When accessing the bladder percutaneously forms an anterior approach, care should be taken to avoid the inferior
epigastric arteries which course along the lateral aspects of
the rectus muscle.
96
A. Donithan et al.
Uterus
The uterus is a hollow thick-walled bromuscular organ
composed of an inner endometrium and outer myometrium.
It is located within the pelvis, posterior and superior to the
bladder, when in its usual anteverted and anteexed orientation (Figs. 7.13 and 7.14). The uterus is composed of the
cervix and body. The cervix is the inferior portion of the
uterus that protrudes into the vagina. The junction of the
cervix and the body is the isthmus, an area where the uterus
narrows. The upper two thirds of the uterus is termed the
body, with the uterine fundus located along the terminal
extent between the fallopian tubes. Uterine version (anteverted or retroverted) is the angle of the cervix relative to the
vagina, and uterine exion is the angle of the uterine body
relative to the cervix.
The uterus is an extraperitoneal organ. The peritoneum
lies over the bladder dome and anterior to the uterus forming
the vesicouterine pouch (anterior cul-de-sac) and extends
posterior around the uterus forming the rectouterine pouch
(posterior cul-de-sac) (Fig. 7.14). The fallopian tubes are
attached to the fundus of the uterus and connect with the
peritoneum.
The uterine artery is supplied by the anterior division of
the internal iliac artery. It passes anterior the ureter at the
level of the cervix and courses along the uterus to anastomose
with the ovarian artery.
While solid organ anatomy is relatively straightforward
on cross-sectional imaging, it is important to have a solid
foundation of the basics in order to understand congenital
and surgical variants. Moreover, recognizing anatomic relationships becomes relevant when viewing anatomy in complex imaging planes for procedural planning.
References
1. Shriki J.Ultrasound physics. Crit Care Clin. 2014;30(1):1–24.
2. Ginat DT, Gupta R.Advances in Computed Tomography Imaging
Technology. Annu Rev Biomed Eng. 2014 07/11; 2017/08;
16(1):431–453.
3. Ridgway JP.Cardiovascular magnetic resonance physics for clini-
cians: part I.J Cardiovasc Magn Reson. 2010;12(1):71.
4. Rogosnitzky M, Branch S.Gadolinium-based contrast agent tox-
icity: a review of known and proposed mechanisms. Biometals.
2016;29(3):365–76.
Part II
Vascular Access
Vascular Access Techniques andClosure
Devices
VivianLeeBishay, RossB.Ingber, PaulJ.O’Connor,
andAaronM.Fischman
8
Arterial Access
Vascular access is the initial skill to master for the interventional radiologist in training, as it is the rst step in performing any endovascular procedure. Evaluating vessel patency
proximal and distal to the site of puncture is important to
ensure successful needle entry. Recording of distal pulse
strength and marking pulse location should be part of the
physical exam prior to vascular access as it provides an
essential baseline for post-procedure comparison.
Percutaneous arterial access is most often achieved using the
Seldinger technique, rst described by Sven Seldinger in
1953 [1]. Traditionally, the arterial pulse would be palpated
using one hand, while the other hand advances a sharp, hollow, bevel-tipped needle into the artery; with advances in
imaging, this is now commonly performed under image
guidance.
V. L. Bishay · P. J. O’Connor
Icahn School of Medicine at Mount Sinai, Divisions of
Interventional Radiology,
New York, NY, USA
e-mail: vivianbishay@mountsinai.org;
paul.oconnor@mountsinai.org
R. B. Ingber
SUNY Downstate Medical Center, College of Medicine,
Brooklyn, NY, USA
e-mail: ross.ingber@downstate.edu
A. M. Fischman (
Icahn School of Medicine at Mount Sinai, Department of
Radiology, New York, NY, USA
e-mail: aaron.schman@mountsinai.org
*)
The How to : Arterial Access
The Seldinger Technique 8.1)
1. If performing femoral access, the femoral head
and marked on the patient’s skin. Ve ssel entry
should be over the femoral head for ease of compression but below the inguinal ligament.
2. Ultrasound survey of vessel and selection of puncture site.
3.
site.
4. Palpate the arterial pulse and perform dermatotomy
with blunt dissection.
5. Under ultrasound guidance, advance a sharp beveled needle into the artery at a 45-degree angle (see
8.1a). A 21-gauge needle is typically used for
access; however, a larger 19-gauge needle is still
preferred by many operators.
6. ther to ensure the entire bevel is inside the vessel to
8.1b).
7.
advance gently into the artery lumen. These wires
are chosen as they are least likely to traumatize the
vessel. The wire should advance with little resis-
8.1c).
8. Remove access needle using the push-pull technique
and advance a sheath over the wire while holding
8.1d–f). A
sheath is a short-tapered hemostatic catheter that
provides a stable conduit through which catheters
can be advanced and navigated into the arteries of
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_8
99
100
V. L. Bishay et al.
Fig. 8.1 Seldinger technique. (a) The needle is advanced at a 45-degree
angle through the soft tissues and used to puncture the anterior wall of
the artery creating an arteriotomy. (b) Once return of blood is seen, the
needle is advanced a few millimeters more to ensure that the needle tip
is well within the artery lumen. (c) A wire is advanced through the nee-
Key Point
Catheter exchange
Push-pull is a misnomer—the goal is to keep the wire
steady while moving the overlying catheter.
dle into the artery lumen. (d) The needle can then be backed out over
the wire, leaving only the wire within the artery. (e–f) A short-tapered
hemostatic catheter known as a sheath can then be tracked over the wire
and into the artery providing stable and hemostatic access into the
artery
Double-Wall Technique
The “double-wall technique” involves inserting the needle
through both the anterior and posterior walls of the artery
until the femoral head is felt rmly against the needle tip. The
needle is then slowly withdrawn until pulsatile blood is seen.
This technique is employed in patients with signicant plaque
or when the single wall technique is otherwise unachievable.
8 Vascular Access Techniques andClosure Devices
101
Both ultrasound and uoroscopy can be helpful in identifying
a heavily calcied artery and pinpointing an area without
calcication for puncture, which may also minimize access
closure complications. When available, preoperative crosssectional imaging should always be reviewed to identify
potential pitfalls of a chosen access site.
Key Point
Double-wall technique
Puncture of the vessel wall through the anterior and
posterior walls followed by slow retraction of the needle tip until pulsatile blood is seen.
Common Femoral Artery Access
Due to the large size and supercial location of the common
femoral artery (CFA) anterior to the femoral head, this artery
remains the standard access point for the majority of arterial
interventions today. Located within the femoral triangle, the
CFA is anatomically bound superiorly by the inguinal ligament, medially by the adductor longus muscle, and laterally
by the sartorius muscle. The inguinal ligament is the anatomic landmark between the retroperitoneal external iliac
artery and the CFA, located within the anterior compartment
of the thigh as it courses over the surface of the femoral head.
Caudally, the CFA bifurcates into the supercial and deep
femoral arteries (Fig. 8.2). Accessing the CFA segment of
the femoral artery is critical to avoid potentially catastrophic
access site-related complications. Inadvertent puncture of
the artery superior to the inguinal ligament can result in difcult or impossible artery compression with an increased
risk for retroperitoneal hemorrhage. Similarly, inadvertent
puncture below the bifurcation into the supercial or deep
femoral arteries can lead to thigh hematoma with no underlying
bony structure against which to compress the artery. It is
important to pick an entry point into the CFA that will allow
for successful manual compression against the femoral head
to achieve arterial hemostasis following sheath removal.
Proper localization of the optimal entry point into the artery
is achieved by placing a radiopaque object, such as a metal
clamp, over the inferomedial border of the femoral head
using uoroscopy [2]. This site can be marked on the skin
and then conrmed under ultrasound guidance (Fig.8.3).
Fig. 8.2 Femoral artery angiogram via arterial sheath with landmarks:
(a) inferior epigastric artery, (b) femoral head, (c) sheath and wire with
arteriotomy in the common femoral artery over the femoral head, (d)
supercial femoral artery, and (e) profunda femoris artery
Fig. 8.3 (a) AP view demonstrating clamp placed over site of skin entry
in preparation for left common femoral artery puncture. (b) Transverse
ultrasound view of the right common femoral artery and vein, note the
artery lateral to the vein. (c) Sagittal view of the right common femoral
artery with needle and wire within the artery lumen