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Interventional procedures in Hepatobiliary system
1.Oncologic therapeutic procedures :Tumor Embolization : Method that
promotes tumor destruction by embolization of its suppliers vessels.◦ Hepatic radioembolization
Tumor Ablations : Percutaneous local tumor destruction by using a device to cause cell death.
2.Vascular Interventions
Trans-jugular intra hepatic portosystemic shunt (TIPS)
Transjugular liver biopsy (TJLB)
3.Biliary interventions :Percutaneous or endoscopic (ERCP)Percutaneous transhepatic
cholangiography (PTC)Percutaneous transhepatic biliary
drainage (PTBD)Percutaneous cholecystostomy (PC)
4.Others
Percutaneous liver biopsyUltrasound guided CT guidedPercutaneous collections drainage Ultrasound guided CT guided
Liver Cancer Treatments
Tumors need a blood supply, which they actively generate, to feed themselves and grow.
In treating cancer patients, interventional radiologists attack the cancer tumor from inside the body without medicating or affecting other parts of the body by using embolization and radiofrequency heat.
Chemoembolization delivers a high dose of cancer-killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor.
In treating cancer patients, interventional radiologists use embolization to cut off the blood supply to the tumor (embolization), deliver radiation to a tumor (radioembolization), or combine this technique with chemotherapy to deliver the cancer drug directly to the tumor (chemoembolization).
Chemoembolization is a minimally invasive treatment for liver cancer that can be used when there is too much tumor to treat with radiofrequency ablation (RFA), when the tumor is in a location that cannot be treated with RFA, or in combination with RFA or other treatments.
Using imaging for guidance, a tiny catheter up the femoral artery in the groin into the blood vessels supplying the liver tumor.
ChemoembolizationThe embolic agents keep the
chemotherapy drug in the tumor by blocking the flow to other areas of the body. This allows for a higher dose of chemotherapy drug to be used, because less of the drug is able to circulate to the healthy cells in the body.
Chemoembolization is a palliative, not a curative, treatment. It can be extremely effective in treating primary liver cancers, especially when combined with other therapies.
Catheter is placed via a transfemoral approach with tip within the selected hepatic artery
SIR-Sphere size is small enough to gain entry into tumor nodules but too large to
pass through the end capillary bed into the venous circulation
SIR-Sphere size is small enough to gain entry into tumor nodules but too large to
pass through the end capillary bed into the venous circulation
Tumor vessels 25μm -75μmEnd arterioles 8 μmSIR-Spheres mean diameter 35 μm
Yttrium-90 Radioembolization
Radioembolization is very similar to chemoembolization but with the use of radioactive microspheres. This therapy is used to treat both primary and metastatic liver tumors.
This treatment incorporates the radioactive isotope Yttrium-90 into the embolic spheres to deliver radiation directly to the tumor. Each sphere is about the size of five red blood cells in width.
These beads are injected through a catheter from the groin into the liver artery supplying the tumor. The beads become lodged within the tumor vessels where they exert their local radiation that causes cell death
This technique allows for a higher, local dose of radiation to be used, without subjecting healthy tissue in the body to the radiation.
Radioembolization is a palliative, not a curative, treatment-but patients benefit by extending their lives and improving their quality of life. It is a relatively new therapy that has been effective in treating primary and metastatic liver cancers. It is performed as an outpatient treatment.
TIPS
Portal hypertension condition in which the normal flow of blood through the liver is slowed or blocked by scarring (cirrhosis) or other damage (e.g. hepatitis). Patients with the condition are at risk of internal bleeding or other life-threatening complications. Transjugular intrahepatic portosystemic shunt (TIPS) formation is a minimally-invasive treatment to alleviate this impaired blood flow.
Indications1. Prevention of variceal bleeding2. Acute bleeding of esophageal varices
that is refractory to medical therapies3. Esophageal variceal rebleeding4. Bleeding from gastric varices5. Prevention of bleeding from portal
hypertensive gastropathy 6. Ascites due to cirrhosis7. Budd-Chiari syndrome8. Veno-occlusive diseases
Absolute contraindications
1. Congestive heart failure2. Multiple hepatic cysts3. Uncontrolled systemic infection
or sepsis4. Unrelieved biliary obstruction5. Severe pulmonary hypertension.
Relative contraindications
1. Hepatoma2. Obstruction of all hepatic veins3. Portal vein thrombosis4. Thrombocytopenia of less than
20,000/cm(3)5. Severe coagulopathy6. Moderate pulmonary
hypertension
TIPS• A catheter is placed in the
right jugular vein
• The catheter is threaded through the superior and inferior vena cava to the hepatic vein
• Wall of the hepatic vein is punctured and the needle is directed across an approximate 2 inch gap to the portal vein
• Successful passage into the
portal vein is determined by the pattern of dye injected through the catheter
TIPS
• A guide wire is threaded through the needle to maintain the passage between the hepatic and portal veins
TIPS
• A balloon may be used across the passage to widen the holes in the vessel walls and the passage through the liver tissue
Biliary interventions :Percutaneous or endoscopic (ERCP)Percutaneous transhepatic
cholangiography (PTC)Percutaneous transhepatic biliary
drainage (PTBD)Percutaneous cholecystostomy (PC)
There is a 5-15% incidence of retained stones after cholecystectomy
Associated with increased risk of recurrent biliary obstruction, pancreatitis, and cholangitis.
Benign/malignant strictures.
ERCPThe diagnostic procedure of choice for abnormalities of the biliary and pancreatic ducts offers options of intervention:Stone extractionSphincterotomyPlacement of stents
A side viewing endoscope is advanced into the descending duodenum the papilla of Vater is identified and cannulated contrast is injected to visualize the pancreatic duct and biliary duct systems
Causes for ERCP failure include:Upper GI stricture/stenosisComplete ductal obstruction
limiting retrograde fillingPostsurgical biliary-enteric fistulaTechnical failure
MRCP is an effective alternative when ERCP is unsuccessful
Percutaneous Transhepatic CholangiographyOld reliableAccurate technique for defining the
site of obstructionProvides option of tissue biopsy and/or
intervention with drain or stentHas been largely replaced by non-
invasive techniques
Indications
Failed ERCP / ERCP not feasible (e.g. patients with gastrojejunostomy)
Biliary system delineation in presence of intra and extrahepatic biliary calculi
To identify obstructive cause of jaundice; and differentiate from medically treatable cause
Anatomic evaluation of complications of ERCP
Delineating bile leaks
Contraindications
Bleeding diathesisGross ascites
Technique◦Standard technique: Thin needle
puncture in ninth or tenth intercostal space
◦Contrast injected during slow withdrawal of the needle under fluoroscopic guidance
◦When duct placement confirmed, additional injection
◦Films taken in AP, right and left oblique
Surgical resection offers potential for cure but is rarely possible
Palliation alternatives:
1. Surgical bypass2. Percutaneous drainage3. Endoscopic or percutaneous
stent placement
Three types of drains:External – does not cross obstruction, drains percutaneously
Internal-external – bile in obstructed segment enters through the side holes of the catheter and emerges beyond the obstruction; the external segment can be capped
Internal – drains only into enteric system
Percutaneous cholecystostomy
Image-guided placement of drainage catheter into gallbladder lumen. This minimally invasive procedure can aid stabilization of a patient to enable a more measured surgical approach with time for therapeutic planning.
Indications
poor surgical candidate/high risk patients with acute calculous or acalculous cholecystitis.
unexplained sepsis in critically ill patients (Diagnostic for cholecystitis as etiology of sepsis if clinical improvement after cholecystostomy).
access to or drainage of biliary tree following failed ERCP and PTC.
Contraindications
Absolute contraindicationsusually noneRelative contraindicationsbleeding diathesis: all attempts should
be made to correct coagulopathy.ascitesgallbladder tumor that might be
seededgallbladder packed with calculi
preventing catheter insertion
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