介入放射学历史

InterventionalRadiology

介入放射学

TONGXiao-qiang

佟小强

Dept,ofInterventionalRadiology&VascularSurgery

TheFirstHospitalofPekingUniversity

介入血管外科，北京大学第一医院

讲课内容

第一部分：介入放射学总论

■什么是介入放射学

■■介入放射学历史

■■介入放射学所需器械

“介入放射学适应证

第二部分：介入放射学各论

■■介入放射学在血管系统的应用

通，堵，注，取

■■介入放射学在非血管系统的应用

通，堵，注，取

重点

1.了解介入放射学的概念

2.了解介入放射学的适应证

3.掌握介入放射学的技术内容:

通,堵,注,取

4.掌握常用专业英文词汇

第一部分介入放射学总论

•什么是介入放射学

•介入放射学历史

•介入放射学所需器械

介入放射学适应证

Radiology

PurposeofRadiology-diagnosis

•X-ray

Computedtomography(CT)

MagneticResonanceImaging(MRI)

•Ultrasound

Radioisotope(RI)

•Angiography

Angiography-early^InterventionalRadiology”

--diagnosis

Vasculardisease

-Occlusion

-Stenosis

-Aneurysm

-Arterio-venousmalformation

-Arteriovenousfistula

-Hemorrhage

Hypervasculartumor

-Hepatocellularcarcinoma

-Renalcellcarcinoma

Relationshipbetweenvesselandtumor

Angiography

•Insertaneedleorcatheterdirectly

intoavessel

Injectsomecontrastmedia(CM)

Takefilms/movie

Achievediagnosis

TraditionalangiographyDSA

Diagnosisonangiography

—stenosisofartery

Dilateit!!!

DiagnosisTreatment

Radiologistintervened

clinicalissuesfrom

diagnosisaloneto

therapeuticactivities.

Dr.Dotter

HistoryofInterventionalRadiology-1

1895：Roentgen发现X射线（诺贝尔奖）

1895：Hascnek首次在截肢术上作动脉造影尝试

1896：Morton开始做尸体动脉造影研究

1904：Dawbam开始肿瘤手术术前栓塞（颈外动脉）

1910：Franck等成功将造影剂注射到活体动物动脉内

1923：Verberich将造影剂注入到人体血管内造影

1924：Brooks成功进行第一例股动脉造影

1927：Maniz成功施行颈动脉直接穿刺造影

1929：DosSantos成功施行经皮腹主动脉穿刺造影

1929：Forssman从上臂静脉将导尿管插入自己的右心房首创

心导管造影术（诺贝尔奖）

1941：Farmas采用股动脉切开法施行主动脉造影

1953：Seidinger首创经皮股动脉穿刺法:简便易行（诺贝尔奖）

HistoryofInterventionalRadiology-2

1956:Oedman等改进了导管头的弯度

1964:Dotter成功施行首例PTA

1967：Judkins行冠状动脉造影

1967:Richarson首先使用Fogarty球囊导管行颈动脉拉栓术

1968：Newtont成功施行脊髓血管畸形动脉栓塞

1968：Nusbaum等首先报道经动脉导管灌注血管加压素及栓塞剂治疗出血

1969：Kauae首先报道经皮肝穿胆道引流术

1972:Rosch等首先介绍对肝肾等肿瘤进行栓塞

1974:Gruentzig发明双腔球囊导管

1977:Gruentzig成功施行冠状动脉PTA

20世纪80年代：DSA技术

1983：Dotter等报道用银钛合金支架的实验成果

1985：VWight和Palmaz分别报道金属自扩式Z型支架和球囊扩张式支架

1988：Richter等成功实施TIPS治疗严重门静脉高压

1991：Parodi首次用直型内支架行腔内隔绝术治疗腹主动脉瘤

3milestonesinhistoryofIR

•1929年:Forssman将导管插入自己心脏

•1953年:Seidinger穿刺法

1964年:Dotter血管成型术

Neverforget

Forssman

1929:cardioangiography

Neverforget

SvenIvarSeidinger

1953:Seidinger'stechnique

Neverforget

CharlesDotter(1920-1985)

1964:PTAbycoaxialcatheter

Neverforget

CesareGianturco

Neverforget

AndreasGruentzig(1939-1985)

1974:Double-lumenballooncatheter

1977：FirstPTCA

(PercutaneousTransluminalCoronaryAngioplasty)

InterventionalRadiology(IR)

Guidedbyimagingfacility:X-ray,CT,US,MRI

Utilizinginstrumentsasguidewire,catheter,etal

Minimallyinvasive:usuallypuncture

Notonlydiagnosisbuttherapeuticefficacy

1967Margulis：InterventionalDiagnosticRadiology

-aNewSubspecialty(AJR)

1976Wallace：InterventionalRadiology(Cancer)

介入放射学技术

TechniquesofIR

Recanalization,Opening

堵Embolization,Occlusion

注Injection,Infusion

取Drainage,Sampling,Biopsy,Retrieval

其他Filter、and—

开通或再通技术一通Recanalization

Vessel—PTA,stenting,thrombolysis

•Airway—stenting

Gastrointestine—dilatation,stenting

Biliaryduct—drainage,dilatation,stenting

Urinarytract—dilatation,stenting

Tubalobstruction—recanalization

Lacrimalductobstruction—recanalization

Establishchannel—TIPS,drainage

栓塞技术一堵Embolization

tumor:malignancy,benign

AVM,AVF,aneurysm

•bleeding

hypersplenism

others：varices,fistula,priapism

动脉局部药物灌注一注Infusion

Thrombolyticagent

Chemotherapeutics

Sclerosingagent

hemostatics

antibiotics

引流/活检/血样/异物/取石一年Retrieval

Biliarydraining(tumor/lithiasis)

Percutaneousremovalofbiliarycalculi

Percutaneousnephrostomy

Drainingofcyst/abscess

Sampling/biopsy

Retrievalofforeignbody

Percutaneouslumbardiscectomy

ContentofIR

VascularIR

经动脉栓塞：出血,动脉瘤，动静脉畸形，肿瘤等

经动脉药物注入:抗癌药,血管收缩/扩张剂,血栓溶解剂等

血管成型术:气囊,旋切，激光,支架等

•血管内异物取出

•静脉溶/取栓术

静脉栓塞术:消化道静脉曲张,精索静脉曲张等

・下腔静脉滤器放置术

•肝静脉-门静脉分流术

NonvascularIR

支架放置术：消化道,气道,胆道,尿道等

・引流术:胆道,脓肿，囊肿等

•造屡术：胃，膀胱，肾等

•取石术：胆道,胆囊,尿道等

药物注入法:囊肿硬化,骨硬化/成型,溶核等

•旋切/抽吸术:椎间盘脱出

AccessinvascularIR

Typesofarterialapproaches

Rightfemoralartery

Leftfemoralartery

Leftaxillaryartery

Rightaxillaryartery

Translumbaraorta

Brachialarteries

Antegradefemoralartery

Throughasurgicalgraft

Rightfemoralarteryisthepreferredroute

Easilyaccessibleformanipulationsandhemostasis

•Large-calibervessel

Well-definedlandmarksexist

•Mostangiographersareright-handed

•Lowcomplicationratecomparedtootherapproaches

Anatomyoffemoral

puncturesite

antenor

external

inguinalI”

Inferiorepigastric

common

fepioral

UHACB

inliniuf

lubercll

2-4cmbelowtheinguinalligamentsuperficialfemoral

Seidinger'sTechnique

Doublewallpuncture

SeidingerTechnique-conJt

sheath

catheter

TraditionalSeidinger'stechnique

ModifiedSeidingerTechnique

1.Needleintroducedinto制f仪2Gui&w“p田“throughnt«dl«

3.Needlewithdrawn4.Cathetecintroducedoverwire

Single(anterior)wallpuncture

ModifiedSeidinger'sTechnique

ComplicationsofIR

Thereare4typesofcomplications

Puncturesitecomplications

(e.g.,groinhematoma)

Contrastagentcomplications

(e.g.,anaphylactoidreaction)

Catheter-relatedcomplications

(e.g.,vesseldissection)

Therapy-relatedcomplications

(e.g.,CNShemmorhageduringUKadministration)

Puncturesitecomplications

■Minorhematoma,>5%

Majorhematoma(requiresurgicaltherapy)<0.5%

Arteriovenousfistula(AVF),0.05%

Pseudoaneurysm,0.01%

•Vesselthrombosis,0.1%

<Neuritis

•Infection

Contrastcomplications

•Renalfailure

•Cardiacfailure

•Phlebitis(venography)

Anaphylactoidreactions(rarewitharteriography)

Catheter-relatedcomplications

•Cholesterolemboli

Thromboembolism

•Cerebrovascularaccident

Arterialdissection

InstrumentsforIR

Punctureneedle

•Sheath

Guidewire/microguidewire

Catheter/microcatheter

Ballooncatheter

•Stent

•Stent-graft

Distalprotectiondevice

eCoil

•Filter

Snare

Catheter

Thermoplasticmaterials(polyurethaneandpolyethylene)

areverycommonlyusedforcathetermanufacturing

•Nylon:combinedwithpolyurethanetomanufacturehigh-flow,

small-Frenchcatheters

Teflon:verystiff,low-frictionmaterial

Braidedcatheters:internalwiremeshimprovestorquability

Guidewire

Allnonspecialtyguidewirehaveasimilarconstruction:

Centralstiffsteelcorewithadistaltaper

•Wirecoilspringwoundaroundcore

Thinfilamentoussafetywireholdingtheother2componentstogether

MostwiresarecoatedwithTeflontodecreasefriction

Sheath

Short-cathterwithvalveattheendtoavoidreflux

Apatereddilatorforsmoothinsertionthroughawire

Double-lumenPTAballooncatheter

自膨式支架

self-expandingstent

Compressedstent

Expandedstent

球囊扩张式支架

balloon-expandingstent

■KbCH'OX；坟，ct.7,7

远端滤伞保护装置

DistalProtectionDevice(DPD)

DPD

FilterWireEZ^

EmbolicProtocttonSystpm

FilterWireEX™

EmbolicProtectionSystem

EV3

spider

Stent-graft

4majorcontentsofvascularIR

•Embolization

•Thrombolysis

Perctaneoustransluminalangioplasty(PTA)

Vascularstenting

Embolization

Indication：eHemorrhage

-Glbleeding

-Varices

-Traumaticorganinjury

-Bronchialarteryhemorrhage

-Tumors

-Postoperativebleeding

•Vascularlesions

-AVMorAVF

-Aneurysm/Pseudoaneurysm

Preoperativedevascularization

-Renalcellcarcinoma

-AVM

-Vascularbonemetastases

•Other

-Hypersplenism

-Gonadalvarices

-Hepaticchemoembolization

Embolicagents

Temporary

-Surgicalgelatin(Gelfoam)

-Pledgetsarecuttosizetooccludelargevessels;

Gelfoampowderoccludesdistalvesselsandcauses

infarction

•Permanent

-Steelcoil

-Microcoil

-Detachableballoon

-Polyvinylalcohol(Ivalon)

-Absoluteethanol

-Plasticpolymers:glue,tissueadhesive

Complicationsofembolization

•Postembolizationsyndrome(fever,elevatedWBC)

Infectionoftheembolizedarea(administer

prophylacticantibiotics)

Refluxofembolicmaterial(nontargetembolization)

Alcoholcausesskin,nerve,andmuscleinfarctionif

usedintheperiphery;itsuseshouldberestrictedto

solidparenchymalorgans.

Thrombolysis

Indications

-Arterialgraftthrombosis

-Nativevesselacutethrombosis

-Priortopercutaneousintervention

-HemodialysisAVForgraft

-Venousthrombosis

•Complication

-MajorhemorrhageContraindications

requiringterminationAbsolute

ofUK,surgeryor-Activebleeding

transfusion(e.g.,-Intracraniallesion(stroke,tumor)

intracranialbleeding)-Pregnancy

-Nonviablelimb

-Minorhemorrhage

Relative

-Distalembolization-Bleedingdiathesis

-Pericatheterthrombosis-Cardiacthrombus

-Overall,terminationof-Malignanthypertension

therapyisrequired-Recentmajorsurgery

in10%-Postpartum

PTA(PercutaneousTransluminalAngioplasty)

•Indication

-Claudicationorrestpain

-Tissueloss

-Nonhealingwound

-Establishinflowforadistalbypassgraft

-HemodialysisAVForgraft

•Complications

-Groincomplications(sameasdiagnosticangiography)

-Distalembolism

-Dissection

-Arterialrupture(rare)

-Renalinfarctionorfailure(withrenalPTA)

Intravascularstents

Indications:

•Longsegmentstenosis

•Totalocclusion

•UnsuccessfulPTA

Largepost-PTAdissectionflap

•Recurrentstenosis

•Ulceratedplaque

•Renalostiallesion

Venousobstruction,thrombosis

Transjugularintrahepaticportosystemicshunt(TIPS)

■

Timetotakeabreak

第二部分介入放射学各论

•■介入放射学在血管系统的应用

通，堵，注，取

••介入放射学在非血管系统的应用

通，堵，注，取

VascularIR

Transarterialembolization■堵

Embolizationofhemarrhage

Iniumaticinjun,ofspleen.

NCCTshowshyperdense

、ascitessuggestingbleeding.

Spongelparticlesareused

forembolization.

fCT3VVafterembolization

showspartialinfarction

ofthespleen.

□iLLV4

41M,traumaticliverrupture

pseudoaneurysm

ExtravasationofCM

DSA

Post-embolization

fiCRA0

「加

50F,giantaneiinsniofright

internalcarotidartc^ry(C4)

139coils）

（J）：Guglielmi

detachablecoil

IP':Interlocking

detachablecoil

、覆ngiograph

Embolizationoftumor

,00^22.(Primaryhepatocellularcarcinoma(HCC)，

15:56:08

29-APR-2OOO

IltAGE9

Follow-upCT

DSA

Superselectiveembolization

withlipiodol

2002.12

DSA,aortogram

tumor

catheter

DSA,rightrenalarteriogram

Uterinemyoma

Pre-embolization3-mafter

Uterinecervicalcareer:

Pre-operativeembolization

Stage-down

Shrinkageoftumor

Decreasebleeding

Stent-graftforaneurysm

PseudoaneurysmStent-graft

ofrtiliacarterydeployment

Aorticstentgraft

81M,2002.8,CT

Abdominalaorticaneurysm(AAA)

UNIVEF

375:1/1.；

1M,2002.

2004.7,CT

2004.7,DSA

6UAU£SJSOd6U4U£S・8」

Follow-upCT

Follow-upCT

Openoperation

Minimallyinvasive:

Smallinguinalincision

J

TP-1032.0

IMA51EnhancedCT

SEQ9

PlainCT

W、40

nA206*

TI0.75

GT0.0

u

1

FEnhanJed-C

DSA

Hugepseudoaneurysm

ofrt.Subclaviana.

50x12mmWallgraft,

24hafterstenting

Post5m

Post12m

EnhancedCT

VAVVH

CT

Reconstructed

coronalimages

VascularIR

Transarterialinfusion——注

Regionalchemotherapy:

feasibletomostofthemalignanttumors

(livertumorIncludingHCCandmetstases,

urinarybladdercancer,uterinecancer,

breastcancer,lungcancer,malignant

tumorofheadandneck

Selectivethrombolysis

-Arterialgraftthrombosis

-Nativevesselacutethrombosis

-Priortopercutaneousintervention

-HemodialysisAVForgraft

-Venousthrombosis

PulmonaryarterhdemboHsmPAE

(pulmonaryarterialembolism)

Pulmonaryarterialembolism.

“F,2weeksafteroperationofthehip

a)Fillingdefectinrightupper

branchindicatingthrombus.

h)Afterinfusionof1.600,000U

t-PA(tissue-plasminogen

组织纤溶酶原activator).

激活剂(t-PA),)7daysafterinfusionof

6.400.000Ut-PA.

54M,urinarybladdercancer

VascularIR

PTAandstenting——通

Stenosisoftransplantedrenalartery.BalloonPTA

Pre-atherectomyAtherosclerotic

stenosisofrt

commoniliac

Post-atherectomy

r

stenting

Vs

VAvu.r\

41M,claudication,stenting

ex

Angiograms4hafteronset,

completeocclusionofleft

anteriordescendingbranch.

PTCA(balloonandstent)

resultsingoodpatency.

Stent:Palmaz-SchatzSpiral

AcutemyocardialinfarctionStent3mmx14mm.

Renalarterialstenosis

stenting(RAS)

0

.Oms

RAS:

-Hypertension

-Renalfunctionimpairment.

,

•r>Aj.umv.neo,umv.

Stenosisofsubclaviana:stenting

Distalprotectiondevice(DPD)

pre-stentingpost-stenting

Stenosisof

vertebrobasilara.

stenosis

Stentingof

intracranialarteries

Superiorvenacavastenosis

duetolymphno