• Interventional Radiology Treatments

  • What is an IVC filter? An IVC filter is a metal umbrella like device implanted in the inferior vena cava and is designed to allow the passage of normal blood flow to the heart but to prevent dangerous blood clots from traveling from leg veins to the lungs. Without the IVC filter in place, a blood clot traveling to the lung could cause a life-threatening condition called a pulmonary embolism.

    Are all IVC filters the same? There are two types of IVC filters, permanent and retrievable filters. Your doctors will determine which filter is right for your based upon your underlying medical condition and ability to tolerate anticoagulation in the future.

    When should a IVC filter be removed? It is recommended that a retrievable filter be removed when the risk of pulmonary embolism has passed or if a patient can take blood thinners. Removal is recommended as filters can increase risks of new blood clot formation in the legs and abdomen, and some filter types have been found to fracture.

    How is an IVC filter removed? A catheter is inserted into the jugular vein in the neck. Using X-ray guidance the catheter is used to grasp onto the small hook on the top of the filter and to withdraw the filter. Additional techniques can be used when other filter removal techniques have been attempted and failed. These procedures are performed on an outpatient basis with return to normal activities the next day.

    What are the risks associated with IVC removal? The rate of complications is low but do include bleeding, clot formation and minor vascular injury. Each complication, when identified and treated early, can be managed successfully.

    Are routine medications safe to take prior to IVC filter removal? Most routine medications are safe to continue taking. Often times blood thinners may be continued during the procedure however this may be suspended depending upon the expected complexity of the removal. You will be instructed regarding which medications to continue taking and which to stop.

    What is deep vein thrombosis? Deep vein thrombosis occurs when a blood clot (thrombus) forms in a deep vein of the legs. This clot can break loose and travel through the vein system into  the lungs, blocking blood flow resulting in what is called a pulmonary embolism (PE). 

    How do I know if I develop a DVT? Many cases of DVT present without symptoms.  Symptoms can include: Swelling and pain of the leg. The affected leg may feel warm or become red and it may be difficult to walk.

    How is deep vein thrombosis diagnosed? The most common test is a venous ultrasound. A series of ultrasounds may be done to determine if a blood clot is growing or to be sure a new one hasn't developed. 

    What are the complications of DVT? If left untreated, approximately 1/3 of patients with DVT can progress to PE which can be fatal. Thus it is important to seek medical attention immediately should you feel that you have symptoms of a DVT or PE.

    Post thrombotic syndrome (PTS) can occur in 20-50% of patients with DVT. PTS occurs months to years after a DVT and is a result of damage to the veins from blood clots. Symptoms of PTS include chronic leg swelling, skin changes, varicose veins, and venous stasis ulcers. Compression stockings manage symptoms of DVT such as swelling but will not prevent the chances of developing PTS.

    The longer the blood clot sits in the vein, the greater the amount of scarring in the vein takes place which increases the chances of developing PTS. As a result, the sooner you are treated for DVT the less likely you will experience PTS. 

    How is deep vein thrombosis treated?

    • Anticoagulation:  Acute DVT is managed with medications that thin your blood (anticoagulation) such as heparin and warfarin (Coumadin). Blood thinning medications work by allowing blood to flow around a trapped clot while at the same time preventing clot from traveling to the lungs but do not remove the existing clot from the vein. The body’s natural defenses "dissolve" the clot which can take several months.
    • IVC Filter: If you are not able to take blood thinning medications, a small umbrella like metal filter may be implanted in the inferior vena cava, the large vein that returns blood back to the heart. The filter, called an inferior vena cava (IVC) filter, prevents clot from traveling to the lungs.  
    • DVT Thrombolysis: For patients with symptomatic DVT and clot extending into the iliac veins, a procedure known as DVT thrombolysis is commonly performed to rapidly reduce symptoms and remove the clot from the deep veins. A small catheter is inserted into the leg and a very strong clot dissolving medication (TPA) is infused into the clot. Mechanical devices are then used to remove the clot. Often, there is a narrowing of a vein responsible for the DVT and a stent can be placed to keep the vein open. While there is a small risk of bleeding from the procedure, DVT thrombolysis can speed your recovery and has been shown to reduce the chances of developing PTS. This procedure often involves at least a one night hospital stay. 

    Patients with the best outcomes are those who have had symptoms for 10 days or less as this is when the clot is easier to remove. Those with symptoms ranging from 10-30 days also do well. 

    Read the results from the CaVenT Study

    Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial.

    Conventional anticoagulant treatment for acute deep vein thrombosis (DVT) effectively prevents thrombus extension and recurrence, but does not dissolve the clot, and many patients develop post-thrombotic syndrome (PTS). We aimed to examine whether additional treatment with catheter-directed thrombolysis (CDT) using alteplase reduced development of PTS.

    Participants in this open-label, randomised controlled trial were recruited from 20 hospitals in the Norwegian southeastern health region. Patients aged 18-75 years with a first-time iliofemoral DVT were included within 21 days from symptom onset. Patients were randomly assigned (1:1) by picking lowest number of sealed envelopes to conventional treatment alone or additional CDT. Randomisation was stratified for involvement of the pelvic veins with blocks of six. We assessed two co-primary outcomes: frequency of PTS as assessed by Villalta score at 24 months, and iliofemoral patency after 6 months. Analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00251771.

    209 patients were randomly assigned to treatment groups (108 control, 101 CDT). At completion of 24 months' follow-up, data for clinical status were available for 189 patients (90%; 99 control, 90 CDT). At 24 months, 37 (41·1%, 95% CI 31·5-51·4) patients allocated additional CDT presented with PTS compared with 55 (55·6%, 95% CI 45·7-65·0) in the control group (p=0·047). The difference in PTS corresponds to an absolute risk reduction of 14·4% (95% CI 0·2-27·9), and the number needed to treat was 7 (95% CI 4-502). Iliofemoral patency after 6 months was reported in 58 patients (65·9%, 95% CI 55·5-75·0) on CDT versus 45 (47·4%, 37·6-57·3) on control (p=0·012). 20 bleeding complications related to CDT included three major and five clinically relevant bleeds.

    Additional CDT should be considered in patients with a high proximal DVT and low risk of bleeding.

    What is an Endoleak? An endoleak is when there is still blood flow in the aneurysm after endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) with a stent graft. This can occur in one quarter of patients who undergo EVAR. Endoleaks may need to be treated if they cause the aneurysm to increase in size or in rare instances rupture.

    How is an endoleak treated? When an endoleak is small, it needs to be monitored with periodic scans (such as a CAT scan) to make sure that the aneurysm does not enlarge. When an endoleak is larger or the aneurysm expands, the endoleak is treated. Interventional Radiologists treat the most common type of endoleak: Type 2 endoleak. It is caused by flow from collateral arteries into the aneurysm and is repaired using embolization in which the endoleak and/or the arteries feeding the endoleak are blocked.

    What is chemoembolization? Chemoembolization is a palliative treatment for liver cancer. This can be a cancer originating in the liver or a cancer that has spread (metastasized) to the liver from other areas of the body. During chemoembolization, chemotherapy drugs attached to small beads are injected into the artery that supplies blood to the tumor in the liver. This deprives the tumor of oxygen, delivers highly concentrated drugs directly to the tumor and allows that drug to stay longer in the tumor than standard chemotherapy, and there is decreased side effects because the drugs are trapped in the liver instead of circulating throughout the body.

    Will your physician recommend you for this procedure? Chemoembolization only treats tumors in the liver and will have little or no effect on any other cancer in the body. You may be a candidate for chemoembolization if you have the following tumors in which the predominant or only site of disease is the liver: 

    • Hepatoma (primary liver cancer)
    • Metastasis (spread) to the liver from:
    • Colon cancer
    • Carcinoid
    • Ocular melanoma
    • Sarcomas

    Your IR physician may recommend that you have several tests, including liver function blood tests, and a CAT scan or an MRI of your liver during your evaluation for the chemoembolization procedure. Your Interventional Radiologist is looking for: Occlusion of the portal vein, Poor liver function, A blockage of the bile ducts. If you have any of these complications, you may not be a candidate for a chemoembolization procedure.

    What should you expect prior to and during the procedure? The evening before the exam you may not eat or drink anything (NPO). You will arrive at the Vascular Center of Colorado (VCC) at Penrose Hospital prior to your scheduled appointment and will receive an intravenous (IV) line placed in your arm. This will allow the administration of antibiotics and other medications that are needed prior to your chemoembolization procedure.

    Prior to going into the procedure suite, you will meet your Interventional Radiologist and the staff who will be assisting in the procedure. Once in the procedure suite, the Interventional Radiologist will place a small catheter (a small tube) in an artery in your groin and identify the arteries in your liver. The IR physician will then pass the catheter into the branch of the artery supplying blood to the tumor, and the chemoembolization mixture is injected. After the procedure you will be admitted to the hospital for observation where you will lie flat in bed for four to six hours. More IV fluids are given to you overnight. Most patients are discharged from the hospital the following day.

    Are there any side effects or complications? Following the procedure you may have varying degrees of pain, fever and nausea (symptoms of post embolization syndrome). These symptoms may last a few hours to a few days, and are easily treated by various medications. Serious complications from chemoembolization are rare and include liver failure and liver abscess.

    Will chemoembolization help me? Remember this is a treatment, not a cure. Approximately 70% of the patients will see improvement in the liver malignancy and potentially longer life expectancy depending upon the type of liver tumor. Because the liver receives two blood supplies (hepatic artery and portal vein), chemotherapy drugs injected into the hepatic artery in the liver reach the tumor very directly, sparing most of the healthy liver tissue. When the artery is blocked, nearly all of the blood supply is taken away from the tumor, while the normal liver continues receive nutrients from the portal vein blood supply. 

    What is uterine artery embolization (UAE)? Uterine artery embolization, is a cutting edge minimally invasive treatment for uterine fibroids performed by an Interventional Radiologist. In this procedure, blood supply to the fibroid tumors is blocked, making them shrink and alleviating symptoms related to fibroids. As an alternative to hysterectomy, uterine artery embolization preserves a woman's uterus, maintains her hormonal cycles and requires far less recovery time. During uterine artery embolization, a catheter is inserted through a blood vessel in the leg and guided by X-rays into the blood vessels that feed the fibroids of the uterus. Small bead-like particles are injected to stop blood flow to the fibroids. Once blood flow to the fibroids is cut off, they shrink gradually over the next weeks and months.

    What are symptoms of uterine fibroids? Fibroids are the most common type of abnormal non cancerous growth in the uterus and can cause pelvic pain, heavy bleeding and infertility. Fibroids can range in size from smaller than an apple seed to larger than a small melon. More than of women with fibroids do not have any symptoms. Women may develop symptoms of bleeding, pelvic pressure, or infertility. Symptoms are usually caused by fibroids that compress the bladder, sciatic nerve and bowel, resulting in urinary frequency, pain, or constipation. Uterine fibroids may impact fertility by the lining of the uterus where fetal implantation occurs.

    How common are uterine fibroids? Approximately one quarter of premenopausal women suffer from fibroids, while the overall prevalence of these tumors could be as high as 75%. Fibroids may occur at any age, but are most common in women over the age of 40 years. After menopause, fibroids usually shrink in size naturally due to the lack of hormonal stimulation. 

    How are uterine fibroids diagnosed? The most common imaging study performed for uterine fibroids is magnetic resonance imaging (MRI) or ultrasound for patients with bleeding or pelvic pain. This test shows the number of fibroids and their location within the uterus. An endometrial biopsy, where a uterine tissue sample is removed through a small tube and examined surgically, may also be recommended prior to undergoing the procedure to exclude other causes of bleeding. Often, the preferred treatment for symptom-free fibroids is to do nothing at all other than monitor their growth. Because fibroids can interfere with fertility and mask other serious problems, regular monitoring and accurate diagnosis are important.

    Uterine artery embolization is a very effective procedure with an approximate success rate of 85%. Most women who undergo UAE have a dramatic improvement in their symptoms and a decrease in size of their uterine fibroids. If menstruation has been heavy, it will usually return to a more normal flow after UAE.

    What is tumor ablation? Tumor ablation is the application of heat or intense cold to cause the death of tumor cells. These procedures are done through a small incision often with sedation and local anesthesia.

    What are the different types of tumor ablation? Radiofrequency ablation (RFA) uses a high-frequency electrical wave and Microwave ablation (MWA)  uses microwaves delivered through a probe or antennae the size of a long pencil to heat and "burn" the tumor. Only the tumor is treated while surrounding healthy tissue is preserved. CT or ultrasound imaging is used to insert the probe into the tumor and kill the cancer cells in as little as 30 minutes. Cryoablation uses liquid nitrogen or argon gas to freeze tumor cells, which then die from the cold temperature. The above types of ablation may be used to treated liver, kidney, bone, and lung tumors. 

    Is tumor ablation a cure for my cancer and is it better than surgery? In general, tumor ablation is used either by itself or in conjunction with other image-guided procedures that we offer to treat your cancer. Tumor ablation is considered palliative and may dramatically shrink your tumor. However depending on the size of your tumor, tumor ablation can be curative, especially for tumors that at 3 cm or less in diameter. In fact, in some studies, tumor ablation is almost equal to surgical resection of a tumor. Your Interventional Radiologist will discuss the best treatment option and whether tumor ablation is right for you.

    Are there any side effects with tumor ablation? All of the tumor ablation modalities are safe and effective and may be repeated multiple times. Some patients may experience flu-like symptoms and some soreness for a few days after the procedure. These symptoms are easily treated with medication. Serious complications are rare and occur in approximately 1 percent of patients.

    What is a varicocele? A varicocele are dilated veins in the scrotum which usually occur on the left side in young men. This condition affects approximately one quarter of the general male population and up to 40% of infertile males.

    How did I get a varicocele? Blood flow normally leaves the testicles through a network of veins. Backflow of blood to the testicles is prevented by a series of one-way valves in the vein. However if these veins do not work well, the blood flows in reverse and causes enlargement of the network of small veins around the testes, forming a varicocele.

    What are the symptoms of a varicocele? Most varicoceles do not cause symptoms, however, they can result  in dull or aching testicular pain especially when the person has been in upright position for a long time. Heavy lifting may make things worse. 

    In some individuals, a varicocele may cause decreased fertility or infertility due to increased testicular temperature which adversely affects the sperm count and quality. At least 50% of men will have improvement in the sperm count and quality after treatment of the varicocele.

    Varicoceles can also cause shrinking of the testicles which may return to normal size after treatment of the varicocele.

    How is a varicocele diagnosed? The majority of varicoceles are detected by a physician during a health checkup and can be confirmed by Ultrasound. 

    Do I need to be treated? In many cases, the varicoceles cause no symptoms and do not need to be fixed. However, if there is associated pain, decreased fertility, or testicular shrinking, treatment may help. All adolescents with varicoceles should be treated to avoid future infertility.

    What are the available treatments? Varicoceles may be treated surgically by a urologist (varicocelectomy) or by a minimally invasive method (varicocele embolization) by an Interventional Radiologist.
    Embolization requires no stitches or general anesthesia and only a 1/4 of an inch incision. The procedure is an outpatient procedure and patients can return to normal activities in two to three days. Surgical treatment requires an incision and may require several days or even weeks to return to full activities. Studies have shown that embolization and surgery are equally effective.

    Regardless of the treatment, the varicocele may recur and may require repeat treatment. If the varicocele has been previously treated with surgery, embolization is still an option. 

    How is embolization performed? Varicocele embolization is usually performed on an outpatient basis under sedation and local anesthesia. A small catheter is inserted into a leg vein near the hip or neck vein through a tiny skin incision. This tube is placed into the gonadal vein supplying the varicocele under X-ray guidance. Small coils or other materials are inserted in the vein to block it and stop the backflow in the varicocele. Blood can still exit the testicle through other normal pathways. 

    How well does embolization work? There is a 90% success rate with embolization with 10% of patients experiencing late recurrence. These results are the same as those achieved with more invasive surgical techniques. Varicocele embolization has been performed for over two decades and has an excellent long-term safety and efficacy which has been shown in very large trials.

    Are there any complications associated with varicocele embolization? Minor complications such as bruising at the entry site, mild backache, or nausea (rare) may occur. Complications associated with surgery such as hydrocele (collection of fluid in the testes), infection, or loss of testicles, are exceedingly rare with an embolization procedure. Embolization also does not affect sexual function. Sexual activity may be resumed the day after the embolization. However, since it takes sperm about three months to mature, improvement in fertility may take three months or longer.

    What is peripheral vascular disease? Peripheral vascular disease (PVD) is a common circulation problem in which the arteries that carry blood to the legs or arms become narrowed or clogged. PVD is sometimes called peripheral arterial disease, or PAD. Many people also refer to the condition as "hardening of the arteries." This interferes with the normal flow of blood, sometimes causing pain but often causing no symptoms at all.

    What causes peripheral vascular disease? The most common cause of PVD is atherosclerosis (often called hardening of the arteries). Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called "plaque" that clogs the blood vessels. In some cases, PVD may be caused by blood clots that lodge in the arteries and restrict blood flow.

    How common is peripheral vascular disease? PVD affects about one in 20 people over the age of 50, or eight million people in the United States. More than half the people with PVD experience leg pain, numbness or other symptoms, but many people dismiss these signs as "a normal part of aging" and don't seek medical help. Only about half of people with these symptoms have been diagnosed with PVD and are seeing a doctor for treatment.

    What are the symptoms of PVD? The most common symptom of PVD is painful cramping in the leg or hip, particularly when walking. This symptom, also known as "claudication," occurs when there is not enough blood flowing to the leg muscles during exercise. The pain typically goes away when the muscles are given a rest. Other symptoms may include numbness, tingling or weakness in the leg. In severe cases, you may experience a burning or aching pain in your foot or toes while resting, or develop a sore on your leg or foot that does not heal. People with PVD also may experience a cooling or color change in the skin of the legs or feet, or loss of hair on the legs. In extreme cases, untreated PVD can lead to gangrene, a serious condition that may require amputation of a leg, foot or toes. If you have PVD, you are also at higher risk for heart disease and stroke. Unfortunately, the disease often goes undiagnosed because many people do not experience symptoms in the early stages of PVD or they mistakenly think the symptoms are a normal part of aging.

    How is peripheral vascular disease diagnosed? The most common test for PVD is the ankle-brachial index (ABI), a painless exam in which a special stethoscope is used to compare the blood pressure in your feet and arms. Based on the results of your ABI, as well as your symptoms and risk factors for PVD, the physician can decide if further tests are needed. When the ABI indicates that an individual may have PVD, other imaging techniques may be used to confirm the diagnosis, including duplex ultrasound, magnetic resonance angiography (MRA) and computed tomography (CT) angiography. The ABI is a simple, painless test to help your physician determine if you have PVD. The blood pressure in your arms and ankles is checked using a regular blood pressure cuff and a special ultrasound stethoscope called a Doppler. The pressure in your ankle is compared to the pressure in your arm to determine how well your blood is flowing and whether further tests are needed. If you suspect that you may have PVD, it is important that you see your personal physician or an interventional radiologist for an evaluation. You also may want to participate in Legs For Life - National Screening for PVD Leg Pain. To find out about this free screening program near you, visit the Legs For Life website. 

    What procedures are available to help? There are a number of ways that physicians can open blood vessels at the site of blockages and restore normal blood flow. In many cases, these procedures can be performed without surgery using modern, interventional radiology techniques. Interventional radiologists are physicians who use tiny tubes called catheters and other miniaturized tools and X-rays to do these procedures. Sometimes, open surgery is required to remove blockages from arteries or to bypass the clogged area. These procedures are performed by vascular surgeons. 

    Interventional Radiology Treatments for PVD: 

    • Angioplasty: A tiny balloon is placed in the blood vessel at the site of the blockage. It is then inflated to open the blood vessel.
    • Stents: A tiny metal cylinder, or stent, is inserted in the clogged vessel to act like a scaffolding and hold it open.
    • Thrombolytic therapy: This treatment is implemented by an interventional radiologist if the blockage in the artery is caused by a blood clot. Thrombolytic drugs-sometimes called "clot busters" dissolve the clot and restore blood flow. Usually, the drugs are administered through a catheter directly into the clot. These drugs are frequently combined with another treatment, such as angioplasty.
    • Stent-grafts: A stent covered with synthetic fabric is inserted into the blood vessels to bypass diseased arteries. 

    Are there any surgical treatments for PVD?  Most cases of PVD can be treated with lifestyle changes, medications, non-surgical interventional radiology procedures, or some combination of these treatments. In some severe cases surgery may be required. Procedures performed by a vascular surgeon include:

    • Thrombectomy: This procedure is used only when symptoms of PVD develop suddenly as a result of a blood clot. In the technique, a balloon catheter is inserted into the affected artery beyond the clot. The balloon is inflated and pulled back, bringing the clot with it. Thrombectomy usually requires surgery.
    • Bypass grafts: In this procedure, a vein graft from another part of the body or a graft made from artificial material is used to create a detour around a blocked artery. 

    How do I know which treatment will be the best for me?  The best treatment for PVD depends on a number of factors, including your overall health, the location of the affected artery, and the size and cause of the blockage or narrowing in the artery. You should discuss all your treatment options with your physician. Some questions to ask are:Can my PVD be controlled with lifestyle changes? What medications might be appropriate for me? If a procedure is required, am I a candidate for a less invasive, interventional radiology treatment? What are the risks and benefits of the treatment plan prescribed for me? and should be discussed with them.)

    What is radioembolization? Radioembolization is a minimally invasive procedure that combines embolization and radiation therapy to treat tumors in the liver. The procedure is very similar to chemoembolization (described here +link+) except that instead of causing blockage of the artery or administration of chemotherapy, tiny glass or resin beads filled with the radioactive isotope yttrium Y-90 are placed inside the blood vessels that feed a tumor. Once these microspheres, which are filled with the radioactive isotope yttrium Y-90, become lodged at the tumor site, they deliver a high dose of radiation to the tumor and not to normal tissues causing death of the tumors.

    How is radioembolization different that chemoembolization? Besides the delivery of high radiation dose to the tumor instead of chemotherapy, radioembolization does not generally require an overnight hospital stay and is typically well tolerated by patients. An extra simulation procedure (or angiogram) is required to determine if you are a candidate for  treatment and to map the expected area of radiation deposition which is typically performed 1 to 4 weeks prior to  the time of treatment. Radioembolization carries less risk of post embolization syndrome and may cause  fatigue which usually resolves in days to a week. Complications are rare but radiation injury to liver, lung, GI tract, or other organs may occur. 

    How may I benefit from radioembolization? Patients may benefit by extending their lives and improving their quality of life. Some patients who initially have too much tumor to undergo surgery or transplantation may respond well enough to undergo surgery later. Radioembolization is performed as an outpatient treatment and generally is well tolerated, without the need to stay overnight in the hospital.

    What tumors can be treated with radioembolization? Many tumor types have been treated with radioembolization with FDA approvals for the treatment of hepatocellular carcinoma and metastatic colorectal carcinoma. Other malignancies that may be treated include cholangiocarcinoma and metastatic neuroendocrine tumor, melanoma, renal cell, lung cancer, breast, and stomach tumors. 

    • Central Line Placement
    • Hemodialysis Management
    • Minimally Invasive Management of Biliary and Renal Obstruction
    • Transjugular Intrahepatic Portosystemic Shunts (TIPS) and Ascites Management (ASPIRA and DENVER Shunt) 
    • Vertebroplasty and Kyphoplasty 
    • Gastrostomy Tubes
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