What is interventional radiology?

 Interventional Radiology is a subspecialty of diagnostic radiology performed by interventional radiologists (IR's). These physicians perform minimally invasive procedures using imaging (for example x-ray, ultrasound, CT) guidance. Most of these procedures are performed while the patient is under sedation. The IR's at Bethesda North Hospital are board certified in diagnostic radiology and have successfully completed additional training in Interventional Radiology.

Interventional radiologists use there expertise in imaging to guide placement of small instruments such as catheters, angioplasty balloons and stents through the blood vessels and other organ systems to treat disease. These procedures are minimally invasive and in many ways preferable to alternative open surgical treatments in that they offer:

• Less risk
• Shorter recovery with less pain
• No incision
• Outpatient availability in most circumstances
• Less costly

Who does IR at Bethesda North?

Michael Haggerty, M.D.

James Hankin, M.D.

Thomas Seward, M.D.

Dean Shanley, D.O.

What can I expect the day of my procedure in IR?

Most patients will come from home, have there procedure, a short recovery and then return home the same day (outpatient). Most patients will initially be seen in the Same Day Surgery Department at Bethesda North Hospital where they will be assessed and prepared for there procedure (IV placed, blood tests drawn, etc). Shortly before the time of the procedure the patient will be transferred to Interventional Radiology (also known as Special Procedures). Patients will be greeted by an excellent staff of nurses and technologists who will assist the doctor in performing the procedure and monitoring the patient during the time the patient is given a light anesthesia (conscious sedation).

All questions will be answered and the procedure explained thoroughly by the Interventional Radiologist physician. Most procedures take an hour to complete. After the procedure the patient will be transferred back to Same Day Surgery prior to discharge home. The outcome of the procedure will be discussed with the patient and family prior to discharge. A written report of the procedure will be available to the referring physician usually on the same or next day.

May I have a brief description of the types of medical problems treated by IR, and the techniques used by interventional radiologists?

• Arterial vascular
• Venous vascular
• Cancer diagnosis and treatments
• Osteoporosis, back pain compression fractures
• Infections
• Liver disease
• Fertility
• Uterine fibroid embolization
• Bleeding

An aortic aneurysm is a weak area in the aorta, the main blood vessel that carries blood from the heart to the rest of the body. As blood flows through the aorta, the weak area bulges like a balloon and can burst if the balloon gets too big.In the past 30 years, the occurrence of Abdominal Aortic Aneurysms (AAA) has increased threefold. AAA is caused by a weakened area in the main vessel that supplies blood from the heart to the rest of the body. When blood flows through the aorta, the pressure of the blood beats against the weakened wall, which then bulges like a balloon. If the balloon grows large enough, there is a danger that it will burst. Most commonly, aortic aneurysms occur in the portion of the vessel below the renal artery origins. The aneurysm may extend into the vessels supplying the hips and pelvis.Once an aneurysm reaches 5 cm in diameter, it is usually considered necessary to treat to prevent rupture. Below 5cm, the risk of the aneurysm rupturing is lower than the risk of conventional surgery in patients with normal surgical risks. The goal of therapy for aneurysms is to prevent them from rupturing. Once an abdominal aortic aneurysm has ruptured, the chances of survival are low, with 80 to 90 percent of all ruptured aneurysms resulting in death. These deaths can be avoided if an aneurysm is detected and treated before it ruptures.

Approximately one in every 250 people over the age of 50 will die of a ruptured AAA AAA affects as many as eight percent of people over the age of 65 Males are four times more likely to have AAA than females AAA is the 17th leading cause of death in the United States, accounting for more than 15,000 deaths each year. Those at highest risk are males over the age of 60 who have ever smoked and/or who have a history of atherosclerosis ("hardening of the arteries") Those with a family history of AAA are at a higher risk (particularly if the relative with AAA was female) Smokers die four times more often from ruptured aneurysms than nonsmokers 50 percent of patients with AAA who do not undergo treatment die of a rupture

AAA is often called a "silent killer" because there are usually no obvious symptoms of the disease. Three out of four aneurysms show no symptoms at the time they are diagnosed. When symptoms are present, they may include:abdominal pain (that may be constant or come and go) pain in the lower back that may radiate to the buttocks, groin or legs the feeling of a "heartbeat" or pulse in the abdomen .Once the aneurysm bursts, symptoms include:

• severe back or abdominal pain that begins suddenly
• paleness
• dry mouth/skin and excessive thirst nausea and vomiting
• signs of shock, such as shaking, dizziness, fainting, sweating, rapid heartbeat and sudden weakness

Aneurysms

An aneurysm is an abnormal bulge or "ballooning" in the wall of an artery. Arteries are blood vessels that carry oxygen-rich blood from the heart to other parts of the body. An aneurysm that grows and becomes large enough can burst, causing dangerous, often fatal, bleeding inside the body.

Most aneurysms occur in the aorta. The aorta is the main artery that carries blood from the heart to the rest of the body. The aorta comes out from the left ventricle of the heart and travels through the chest and abdomen. An aneurysm that occurs in the aorta in the chest is called a thoracic aortic aneurysm. An aneurysm that occurs in the aorta in the abdomen is called an abdominal aortic aneurysm.

Aneurysms also can occur in arteries in the brain, heart, intestine, neck, spleen, back of the knees and thighs, and in other parts of the body. If an aneurysm in the brain bursts, it causes a stroke.Many cases of ruptured aneurysm can be prevented with early diagnosis and treatment. Because aneurysms can develop and become large before causing any symptoms, it is important to look for them in people who are at the highest risk.

Atherosclerosis and narrowing of the arteries

Atherosclerosis is a disease affecting the arterial blood vessels. It is commonly referred to as a "hardening" or "furring" of the arteries. It is caused by the formation of multiple plaques within the arteries.

Arteriosclerosis ("hardening of the artery") results from a deposition of tough, rigid collagen inside the vessel wall and around the atheroma. This increases the stiffness, decreases the elasticity of the artery wall. Arteriolosclerosis (hardening of small arteries, the arterioles) is the result of collagen deposition, but also muscle wall thickening and deposition of protein ("hyaline"). Calcification, sometimes even ossification (formation of complete bone tissue) occurs within the deepest and oldest layers of the sclerosed vessel wall.Atherosclerosis causes two main problems. First, the atheromatous plaques, though long compensated for by artery enlargement, eventually lead to plaque ruptures and stenosis (narrowing) of the artery and, therefore, an insufficient blood supply to the organ it feeds. Alternatively, if the compensating artery enlargement process is excessive, then a net aneurysm results.

These complications are chronic, slowly progressing and cumulative. Most commonly, soft plaque suddenly ruptures causing the formation of a blood clot that will rapidly slow or stop blood flow, e.g. 5 minutes, leading to death of the tissues fed by the artery. This catastrophic event is called an infarction. One of the most common recognized scenarios is called coronary thrombosis of a coronary artery causing myocardial infarction (a heart attack). Another common scenario in very advanced disease is claudication from insufficient blood supply to the legs, typically due to a combination of both stenosis and aneurysmal segments narrowed with clots. Since atherosclerosis is a body wide process, similar events also occur in the arteries to the brain, intestines, kidneys, legs, etc.

High Blood Pressure (Hypertension)

http://en.wikipedia.org/wiki/Hypertension

Hypertension, commonly referred to as "high blood pressure", is a medical condition where the blood pressure is chronically elevated. While it is formally called arterial hypertension, the word "hypertension" without a qualifier usually refers to arterial hypertension. Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.

Hypertension can be classified as either essential or secondary. Essential hypertension is the term used when no specific medical cause can be found to explain a patient's condition. Secondary hypertension means that the high blood pressure is a result of (i.e. secondary to) another condition, such as renal artery stenosis (RAS), kidney disease or certain tumors. RAS can often be treated by physicians with angioplasty and stent of diseased and narrowed renal arteries.

Recently, the JNC 7 (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) has defined blood pressure 120/80 mmHg to 139/89 mmHg as "prehypertension." Prehypertension is not a disease category; rather, it is a designation chosen to identify individuals at high risk of developing hypertension.

The Mayo Clinic website indicates that your blood pressure is "normal if it's below 120/80" but that "some data indicate that 115/75 mm Hg should be the gold standard."

"In patients with diabetes mellitus or kidney disease studies have shown that blood pressure over 130/80 mmHg should be considered a risk factor and warrants treatment. Even lower numbers are considered diagnostic using home blood pressure monitoring devices.

Peripheral arterial disease

www.sirweb.org/patPub/pvdPad.shtml

Peripheral arterial disease (PAD), also known as peripheral vascular disease (PVD), is a very common condition affecting 12-20 percent of Americans age 65 and older. PAD develops most commonly as a result of atherosclerosis, or "hardening of the arteries," which occurs when cholesterol and scar tissue build up, forming a substance called plaque inside the arteries that narrows and clogs the arteries. This is a very serious condition. The clogged arteries cause decreased blood flow to the legs, which can result in pain when walking, and eventually gangrene and amputation.

Because atherosclerosis is a systemic disease, people with PAD are likely to have blocked arteries in other areas of the body. Thus, people with PAD are at increased risk for heart disease, aortic aneurysms and stroke. PAD is also a marker for diabetes, hypertension and other conditions. This is a major public health issue and the Society of Interventional Radiology recommends greater screening efforts through the use of the ankle brachial index (ABI) test. This simple, painless test compares the blood pressure in the legs to the blood pressure in the arms to determine how well the blood is flowing and if further tests are needed. Each September, during Peripheral Vascular Disease Month, interventional radiologists participate in Legs For Life, a nationwide screening program sponsored by the Society of Interventional Radiology.

Symptoms

The most common symptom of PAD is called claudication, which is leg pain that occurs when walking or exercising and disappears when the person stops the activity.

Other symptoms of PAD include:

• numbness and tingling in the lower legs and feet;
• coldness in the lower legs and feet;
• and ulcers or sores on the legs or feet that don't heal.

Many people simply live with their pain, assuming it is a normal part of aging, rather than reporting it to their doctor.

Prevalence

Peripheral Arterial Disease (PAD) is a disease of the arteries that affects 10 million Americans. PAD can happen to anyone, regardless of age, but it is most common in men and women over age 50. PAD affects 12-20 percent of Americans age 65 and older.

Risk Factors

• Smoking
• High blood pressure (hypertension)
• High cholesterol
• Diabetes
• Family history of heart or vascular disease
• Being overweight
• Lack of exercise or physical activity
• Age over 50

Treatment can be based on standard interventional radiological techniques including thrombolytic therapy, balloon angioplasty and stenting of the diseased arteries.

Stroke

www.sirweb.org/patPub/stroke.shtml

Stroke is the third leading cause of death in the United States behind high blood pressure and cancer. Every 45 seconds someone in the United States has a stroke and every three minutes someone dies from a stroke. In the U.S. alone, an estimated 600,000 individuals will suffer a new or recurrent stroke each year -- 160,000 will die. More than one million American stroke survivors struggle with serious disabilities, including loss of speech and/or language problems, weakness or paralysis, loss of balance or coordination, and confusion and memory loss. All are common impairments in the aftermath of a stroke.

Once it was believed that little could be done to treat stroke. Now we know that if a stroke victim receives emergency care within the first three to six hours of the first symptom, the disabling, long-term effects of stroke may be avoided or greatly reduced. Unfortunately, many people do not recognize the warning signs of stroke or do not know that immediate emergency care can greatly improve their chance of recovery. Studies show that the average person waits 13 hours after experiencing the first symptoms of stroke before seeking medical care, and 42 percent of patients wait as long as 24 hours. It is critical to recognize the symptoms of stroke and seek immediate emergency attention.

What causes stroke?

A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is blocked by a clot or bursts, causing the brain to starve. If deprived of oxygen for even a short period of time, the brain nerve cells will start to die. Once the brain cells die from a lack of oxygen, the part of the body that was controlled by that dead (infracted) part of the brain will malfunction often causing paralysis, numbness, loss of vision, loss of speech or even coma and death.

There are two types of stroke:

Blood clots that block the artery are ischemic (is-KEM-ik) strokes and the most common type, causing between 70-80 percent of all strokes.

When a blood vessel ruptures, it causes a bleeding or hemorrhagic (hem-o-RAJ-ik) stroke. Such strokes are usually the result of a ruptured blood vessel or an aneurysm?a weakened area of a blood vessel that bulges or balloons out. Sometimes, abnormal tangles of blood vessels in the brain, called arteriovenous malformations (AVM) can rupture and cause a hemorrhagic stroke. Approximately 20 percent of strokes are hemorrhagic. This is the most common type of stroke in young people.

There are also "mini-strokes" known as TIA's (transient ischemic attacks). People who have one TIA are likely to have another one. TIAs cause brief stroke symptoms that go away after a few minutes or hours. People often ignore these symptoms, but they are an early warning sign and 35 percent of those who experience a TIA will have a full blown stroke if left untreated. TIAs should be taken as seriously as stroke.T

he leading cause of stroke and TIA is carotid artery disease (CAD). In CAD, a substance called plaque builds up over time in the carotid arteries, the large blood vessels on either side of the neck that supply blood to the head and brain. The buildup of plaque is a silent disease, until small particles break away and are carried to smaller arteries, where they block the flow of blood. The nature and severity of symptoms depend on how large an area of the brain is affected and whether the blood supply to the brain is completely or partially blocked.

What are the symptoms of stroke?

The most common symptoms of stroke are:

• Sudden numbness or weakness in the face, arm and/or leg, especially on one side of the body.
• Sudden confusion, trouble speaking or understanding speech.
• Sudden trouble seeing, including double vision, blurred vision or partial blindness, in one or both eyes.
• Trouble walking, dizziness, loss of balance or coordination.
• Sudden severe, headache with no known cause.

If you experience any of these symptoms, even if they go away quickly, seek immediate emergency help.

Every minute counts. Although starved of oxygen, brain tissue does not die in the minutes following a stroke. If blocked blood vessels can be opened within three to six hours, the chances of recovery are greatly improved.

What are the risk factors for stroke?

People who are at higher-than-average risk for stroke include those who have:

High blood pressure.

High blood pressure, or hypertension, puts stress on the walls of blood vessels and can lead to strokes from blood clots or hemorrhage. Half or more of all stroke victims have uncontrolled high blood pressure. Fortunately, this risk factor for stroke can be controlled. Eating a balanced diet, maintaining a healthy weight and exercising regularly can help control high blood pressure. Medications that lower blood pressure also may be prescribed.

High Cholesterol.

High cholesterol can lead to blockage in the carotid artery that takes blood from the neck to the brain. A piece of this plaque can break off and travel to the brain causing a stroke.

Heart disease.

Approximately 15 percent of all stroke victims have a common heart rhythm disorder called atrial fibrillation, that causes the upper chambers of the heart (the atria) quiver instead of beating which allows the blood to pool and clot. If a clot breaks off and enters the blood stream to the brain, a stroke will occur.

Atherosclerosis.

When the carotid arteries, the major blood vessels that supply blood to the brain, become clogged with atherosclerotic plaque, the risk for stroke goes up. Personal history of stroke or TIA. People who have already suffered a stroke or TIA are at increased risk of having another. Modifying risk factors for stroke, including lifestyle changes (e.g. exercise, stop smoking), medications and/or other treatments can reduce this risk.

Lifestyle risk factors.

Smoking, excessive alcohol consumption and being overweight are all significant risk factors for stroke. High cholesterol can lead to blockage in the carotid artery that takes blood from the neck to the brain. A piece of this plaque can break off and travel to the brain causing a stroke.

Age, gender and race.

The risk of stroke goes up with age, with two-thirds of all strokes occurring in individuals 65 years or older. Twenty-eight percent of stroke occur in people under the age of 65. Males have a slightly higher risk than females although more women die from them. African Americans are at a much higher risk in part because they are at increased risk for obesity, high blood pressure and diabetes which increase the risk for stroke. Family history of stroke or TIA. If others in your family have suffered stroke, you may be at higher risk. Regular physical exams, lifestyle changes and medical treatments may reduce this risk.

Diabetes.

People with diabetes are at increased risk for stroke, although keeping diabetes under control with diet and/or medication may help to decrease the risk.

Sickle Cell Anemia.

Sickle cell anemia makes red blood cells less able to carry blood to the body's tissues and organs, as well as stick to the walls of the blood vessels which can block arteries to the brain causing a stroke. Hyper-homocysteinemia. Elevated homocysteine levels in the blood have been identified as a risk factor for heart attack and stroke that may be as important as high cholesterol. Homocysteine is a by-product of the process that metabolizes methionine, an amino acid essential in human nutrition.

Angioplasty and stent placement.

For In this procedure, the interventional radiologist inserts a very small balloon attached to a catheter intointo a blood vessel through a small skin incision. The catheter is threaded under X-ray guidance to tthethe site of the blocked artery. The balloon is inflated to open the artery.

Sometimes so, a small metal tube, called a stent, is inserted to better keep open the blood vessel.

Thrombolytic Therapy

This treatment is used if the blockage in an artery or vein is caused by a blood clot. Thrombolytic drugs that dissolve clots are injected through a catheter to eliminate the clot and restore blood flow. This procedure is done through a small skin incision through which a small catheter is advanced into the blood vessel with the clot and the clot is dissolved. This is always done in conjunction with angiography, and many times angioplasty or vascular stents may also be required to keep the vessel open. Mechanical thrombectomy may also be performed in this process.

Venous Vascular

Deep Vein Thrombosis

http://www.sirweb.org/patPub/DVTOverview.shtml

Deep vein thrombosis (DVT) is the formation of a blood clot, known as a thrombus, in the deep leg vein. It is a very serious condition that can cause permanent damage to the leg, known as post-thrombotic syndrome, or a life-threating pulomnary embolism. In the United States alone, 600,000 new cases are diagnosed each year. One in every 100 people who develops DVT dies.

Recently, it has been referred to as "Economy Class Syndrome" due to the occurrence after sitting on long flights.

The deep veins that lie near the center of the leg are surrounded by powerful muscles that contract and force deoxygenated blood back to the lungs and heart. One-way valves prevent the back-flow of blood between the contractions. (Blood is squeezed up the leg against gravity and the valves prevent it from flowing back to our feet.) When the circulation of the blood slows down due to illness, injury or inactivity, blood can accumulate or "pool" which provides an ideal setting for clot formation.

Risk Factors

• Previous DVT or family history of DVT
• Immobility, such as bed rest or sitting for long periods of time
• Recent surgery
• Above the age of 40
• Hormone therapy or oral contraceptives
• Pregnancy or post-partum
• Previous or current cancer
• Limb trauma and/or orthopedic procedures
• Coagulation abnormalities
• Obesity

Symptoms

• Discoloration of the legs
• Calf or leg pain or tenderness
• Swelling of the leg or lower limb
• Warm skin
• Surface veins become more visible
• Leg fatigue

Post thrombotic Syndrome

Post thrombotic syndrome is an under-recognized, but relatively common sequela, or aftereffect, of having DVT if treated with blood thinners (anticoagulation) alone, because the clot remains in the leg. Contrary to popular belief, anticoagulants do not actively dissolve the clot, they just prevent new clots from forming. The body will eventually dissolve a clot, but often the vein becomes damaged in the meantime. A significant proportion of these patients develop permanent irreversible damage in the affected leg veins and their valves, resulting in abnormal pooling of blood in the leg, chronic leg pain, fatigue, swelling, and, in extreme cases, severe skin ulcers. While this used to be considered an unusual, long-term sequela, it actually occurs frequently, in as many as 60-70 percent of people, and can develop within two months of developing DVT. There is increasing evidence that clot removal via interventional catheter-directed thrombolysis in selected cases of DVT can improve quality of life and prevent the debilitating sequela of post thrombotic syndrome.

Pelvic pain (chronic)

www.sirweb.org/patPub/chronicPelvicPainInWomen.shtml

It is estimated that one-third of all women will experience chronic pelvic pain in their lifetime. Many of these women are told the problem is "all in their head" but recent advancements now show the pain may be due to hard to detect varicose veins in the pelvis, known as pelvic congestion syndrome.

The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don't close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.

The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing.

Many women with pelvic congestion syndrome, spend many years trying to get an answer to why they have this chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.

Prevalence

• Women with pelvic congestion syndrome are typically less than 45 years old and in their child bearing years.
• Ovarian veins increase in size related to previous pregnancies.
• Pelvic congestion syndrome is unusual in women who have not been pregnant.
• Chronic pelvic pain accounts for 15% of outpatient gynecologic visits.
• Studies show 30% of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15% have PCS along with another pelvic pathology.

Risk Factors

• Two or more pregnancies and hormonal increases
• Fullness of leg veins
• Polycystic ovaries
• Hormonal dysfunction

Symptoms

The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:

• Following intercourse
• Menstrual periods
• When tired or when standing (worse at end of day)
• Pregnancy

Other symptoms include:

• Irritable bladder
• Abnormal menstrual bleeding
• Vaginal discharge
• Varicose veins on vulva, buttocks or thigh.

Varicose Veins

www.sirweb.org/patPub/varicoseVeinMain.shtml

Venous insufficiency is a very common condition resulting from decreased blood flow from the leg veins up to the heart, with pooling of blood in the veins. Normally, one-way valves in the veins keep blood flowing toward the heart, against the force of gravity. When the valves become weak and don't close properly, they allow blood to flow backward, a condition called reflux. Veins that have lost their valve effectiveness, become elongated, rope-like, bulged, and thickened. These enlarged, swollen vessels are known as varicose veins and are a direct result of increased pressure from reflux. A common cause of varicose veins in the legs is reflux in a thigh vein called the great saphenous, which leads to pooling in the visible varicose vein below.

How Common Is This Condition?

Chronic venous disease of the legs is one of the most common conditions affecting people of all races.

Approximately half of the U.S. population has venous disease--50 to 55% of women and 40 to 45% of men. Of these, 20 to 25% of the women and 10 to 15% of men will have visible varicose veins.

Varicose veins affect 1 out of 2 people age 50 and older, and 15 to 25% of all adults.

Risk Factors

• Age
• Family history
• Female gender
• Pregnancy, especially multiple pregnancies, is one of the most common factors accelerating the worsening of varicose veins.

Symptoms

Symptoms caused by venous insufficiency and varicose veins include aching pain, easily tired legs, and leg heaviness, all of which worsen as the day goes on. Many people find they need to sit down in the afternoon and elevate their legs to relieve these symptoms. In more severe cases, venous insufficiency and reflux can cause darkening of the skin and wounds that may be very difficult to treat. One percent of adults over age 60 have chronic wounds known as venous stasis ulcers.

People who have venous insufficiency can have symptoms even without visible varicose veins. The symptoms are caused by pressure on nerves by dilated veins.

Venous access catheters

Central Venous Access Catheters (CVAC)

A CVAC is a tube that is inserted beneath your skin so there is a simple, pain-free way for doctors or nurses to draw your blood or give you medication or nutrients. When you have a CVAC, you are spared the irritation and discomfort of repeated needlesticks. More than 3.4 million CVACs are placed each year, and doctors increasingly recommend their use. There are several types of CVACs, including tunneled catheters (Hickman or Broviac), peripherally inserted central catheters (also called PICC lines or long lines), dialysis catheters, and implantable ports.

Doctors often recommend CVACs for patients who regularly have:

• Chemotherapy treatments
• Infusions of antibiotics or other medications
• Nutritional supplements
• Hemodialysis

Interventional radiologists also open up blocked hemodialysis grafts, using procedures such as angioplasty or thrombolytic therapy.

Blood Clot Filters

Patients with certain chronic illnesses or other conditions that require prolonged periods of inactivity, are at risk of forming blood clots in their leg veins that can break off and travel to the heart or lungs. This can be catastrophic. If this occurs while taking blood thinners, or if patients cannot tolerate blood thinners, they may be a candidate for this procedure. The interventional radiologist can insert a small filter (called a vena cava filter) into a blood vessel through a small skin incision, in either the patient?s leg or neck, and then advance the filter to the correct position under x-ray guidance, to allow the filter to catch and break up blood clots.

Cancer diagnosis and treatments

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 in the body. This is done through a small skin incision placing a catheter into the patient?s arteries and injecting chemotherapy drugs and occluding particles directly into the blood supply to the tumor. This allows a higher concentration of chemotherapy agent directly into the tumor, allows the blood supply to the tumor to be directly cut off and is less toxic to the body since it is given directly into the tumor and not systemically through the patient?s veins.

Radiofrequency Ablation or tumors (RFA):

http://www.sirweb.org/patPub/radiofrequency/Ablation.shtml

http://angiodynamics.com/pages/patients/index.asp

Sometimes referred to as RFA, a special needle electrode is placed in the tumor under the guidance of an imaging method such as ultrasound or computed tomography (CT) scanning. This is performed by an interventional radiologist. A radiofrequency current then is passed through the electrode to heat the tumor tissue near the needle tip and ablate -or eliminate- it. The heat from radiofrequency energy also closes up small blood vessels, thereby minimizing the risk of bleeding. This procedure is generally performed for liver, lung and kidney.

Needle biopsy

www.sirweb.org/patPub/needleBiopsy.shtml

The interventional radiologist uses X-ray, Ultrasound, CAT scan or MRI to guide a skinny needle into any possible abnormality in the body to allow a diagnosis to be made. This most often is done for the lung, liver, kidneys, or a mass anywhere in the body. This is an alternative to open surgical biopsy.Osteoporosis, back pain compression fractures.

Spine Compression Fractures

http://www.sirweb.org/patPub/vertebroplasty.shtml

Approximately 700,000 vertebral, or spinal bone, fractures occur each year, usually in women over the age of 60. Researchers estimate that at least 25 percent of women and a somewhat smaller percentage of men over the age of 50 will suffer one or more spinal fractures. Younger people also suffer these fractures, particularly those whose bones have become fragile due to the long-term use of steroids or other drugs to treat a variety of diseases such as lupus, asthma and rheumatoid arthritis. Of particular concern are spinal fractures caused by a progressive weakening of the bone -- a condition called osteoporosis. The pain and loss of movement that often accompany bone fractures of the spine are perhaps the most feared and debilitating side effects of osteoporosis. For many people with osteoporosis, a spinal fracture means severely limited activity, constant pain and a serious reduction in the quality of their lives.

Fractures of the vertebrae have traditionally been much more difficult to manage than broken bones in the hip, wrist or elsewhere. These broken bones can often be successfully treated with surgery. But because surgery on the spine is extremely difficult and risky, it has typically not been used to treat vertebral fractures associated with osteoporosis except as a last resort. Until recently, reduced activity and pain medications, many of which cause problematic side effects, or invasive (and often unsuccessful) back surgery were virtually the only treatments available. Today, however, there is a safe, non-surgical interventional radiology treatment called vertebroplasty and kyphoplasty that has been shown to be extremely effective in reducing or eliminating the pain caused by spinal fractures.

Kyphoplasty

http://www.kyphon.com

Balloon Kyphoplasty is a minimally invasive treatment performed by interventional radiologists in which orthopaedic balloons are used to gently raise the collapsed vertebra in an attempt to return them to the correct position. Kyphoplasty is a pain treatment for vertebral compression fractures that may result from osteoporosis, cancer, or trauma. If these compression fractures fail to respond to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable, Kyphoplasty may be indicated. Before the procedure, you will have diagnostic studies, such as x-rays and magnetic resonance imaging, to determine the exact location of the fracture.

Vertebroplasty

Vertebroplasty is a pain treatment for vertebral compression fractures that may result from osteoporosis, cancer, or trauma. If these compression fractures fail to respond to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable, Vertebroplasty may be indicated. Vertebroplasty, a non-surgical treatment performed using imaging guidance by interventional radiologists, stabilizes the collapsed vertebra with the injection of medical-grade bone cement into the spine. Before the procedure, you will have diagnostic studies, such as x-rays and magnetic resonance imaging, to determine the exact location of the fracture.

Infections

Infection and Abscess Drainage

An abscess is a localized collection of pus in any part of the body, caused by an infection. Abscesses occur when an area of tissue becomes infected and the body is able to "wall off" the infection to keep it from spreading. Abscesses can form in almost every part of the body and may be caused by infectious organisms, parasites, and foreign materials. Interventional Radiologists (IRs) can insert a drainage catheter into the abscess, under CAT scan guidance, ultrasound guidance, or x-ray guidance to allow drainage to the outside of the body, often times curing the abscess, so that open surgery is not necessary.

Urinary Tract Infections

The ureter, the tube that carries urine from the kidneys to the bladder sometimes becomes blocked by kidney stones or other obstructions. The interventional radiologist inserts a thin tube (catheter) through a small skin incision in the back into the blocked kidney to drain the urine. A stent may sometimes be inserted between the kidney and urinary bladder to unblock the narrowing that caused a blockage.

Liver disease

www.sirweb.org/patPub/liverDisease.shtml

There are a number of problems in the liver that can be treated with nonsurgical, interventional radiology techniques.

Portal Hypertension

Seen most frequently in patients with liver disease such as cirrhosis or hepatitis, portal hypertension is a condition in which the normal flow of blood through the liver is slowed or blocked by scarring or other damage. Patients with the condition are at risk of internal bleeding or other life-threatening complications.

Interventional radiologists treat portal hypertension without surgery, using a procedure called TIPS (transjugular intrahepatic portosystemic shunt). The doctor threads a thin tube (catheter) through a small incision in the skin near the neck and guides it to the blocked blood vessels in the liver. Under X-ray guidance, the doctor creates a tunnel in the liver through which the blocked blood can flow. The tunnel is held open by the insertion of a small metal cylinder, called a stent.

Bile Duct Obstruction

In some patients, such as those with liver cancer or individuals who have had an injury to the liver, the bile ducts become blocked and bile cannot drain from the liver. The interventional radiologist places a thin tube (catheter) through the skin and into the bile ducts to drain the bile. In some cases, a small metal cylinder, called a stent, is placed in the liver to hold the blocked area open. A catheter may also be placed to drain bile in patients who have a hole in the bile ducts or as preparation for surgery on the bile ducts.

Fertility

Infertility

www.sirweb.org/patPub/infertility.shtml

Some common causes of infertility in both women and men can now be treated without surgery by interventional radiologists. Often these treatments do not require hospitalization or general anesthesia. Patients usually may return to normal activity shortly after the procedure.

www.sirweb.org/patPub/uterine.shtml

Uterine fibroids are very common non-cancerous (benign) growths that develop in the muscular wall of the uterus. They can range in size from very tiny (a quarter of an inch) to larger than a cantaloupe. Occasionally, they can cause the uterus to grow to the size of a five-month pregnancy. In most cases, there is more than one fibroid in the uterus. While fibroids do not always cause symptoms, their size and location can lead to problems for some women, including pain and heavy bleeding.

Fibroids can dramatically increase in size during pregnancy. This is thought to occur because of the increase in estrogen levels during pregnancy. After pregnancy, the fibroids usually shrink back to their pre-pregnancy size. They typically improve after menopause when the level of estrogen, the female hormone that circulates in the blood, decreases dramatically. However, menopausal women who are taking supplemental estrogen (hormone replacement therapy) may not experience relief of symptoms.

Fibroid tumors of the uterus are very common, but for most women, they either do not cause symptoms or cause only minor symptoms. Fibroids can cause very heavy menstrual bleeding, clotting and pelvic pain, leading many women to seek treatment. Fibroids often fail to respond to medical therapy and then surgical procedures are often recommended.

Prevalence

Twenty to 40 percent of women age 35 and older have uterine fibroids of a significant size. African American women are at a higher risk for fibroids: as many as 50 percent have fibroids of a significant size. Uterine fibroids are the most frequent indication for hysterectomy in pre-menopausal women and, therefore, are a major public health issue. Of the 600,000 hysterectomies performed annually in the United States, 1/3 of these are due to fibroids.

Uterine Fibroid Embolization (UFE)

Uterine artery embolization is a new procedure aimed at preventing the need for major surgery. The method stops the blood supply that makes fibroids grow. This procedure is done by placing a catheter through a small skin incision in the groin region and advancing the catheter into the arteries that feed the fibroid tumors. Tiny particles are then injected to stop the blood supply to the fibroid tumors. Most women with symptomatic fibroids are candidates for UFE and should obtain a consult with an interventional radiologist to determine whether UFE is a treatment option for them. An ultrasound or MRI diagnostic test will help the interventional radiologist to determine if the woman is a candidate for this treatment.

• http://biospheremed.com/indications/index.cfm?sectionTitle=patients
• http://www.sirweb.org/patPub/uterinePressReleases.shtml
• http://www.sirweb.org/video/UFE.mpg

Bleeding Embolization

Delivery of clotting agents (coils, plastic particles, gel, foam, etc.) directly to an area that is bleeding or to block blood flow to a problem area, such as an aneurysm or a fibroid tumor in the uterus. Again, this is done by placing a catheter through a small skin incision. This is sometimes done by directly placing a needle into the abnormality without using catheters.

These techniques can also be used in uterine artery embolization, varicocele embolization, pulmonary arteriovenous malformation, gastrointestinal hemorrhage, post partum hemorrhage, and traumatic hemorrhage.

What treatments can be preformed for infertility?

www.sirweb.org/patPub/infertility.shtml

Some common causes of infertility in both women and men can now be treated without surgery by interventional radiologists. Often these treatments do not require hospitalization or general anesthesia. Patients usually may return to normal activity shortly after the procedure.

Female Infertility:

Blockage of the Fallopian TubeThe most common cause of female infertility is a blockage of the fallopian tube through which eggs pass from the ovary to the uterus. Occasionally, these tubes become plugged or narrowed, preventing successful pregnancy.

Interventional radiologists can diagnose and treat a blockage in the fallopian tubes with a nonsurgical procedure known as selective salpingography. In the procedure, which does not require an incision, a thin tube (catheter) is placed into the uterus. A contrast agent, or dye, is injected through the catheter, and an X-ray image of the uterine cavity is obtained. When a blockage of the fallopian tube is identified, another catheter is threaded into the fallopian tube to open the blockage.

Varicoceles and Male infertility

www.sirweb.org/patPub/varicoceleOverview.shtml

A varicocele is a varicose vein of the testicle and scrotum that may cause pain, testicular atrophy (shrinkage) or fertility problems. Veins contain one-way valves that work to allow blood to flow from the testicles and scrotum back to the heart. When these valves fail, the blood pools and enlarges the veins around the testicle in the scrotum to cause a varicocele. Open surgical ligation, performed by a urologist, is the most common treatment for symptomatic varicoceles. Varicocele embolization, a non-surgical treatment performed by an interventional radiologist, is a highly effective, widely available technique to treat symptomatic varicoceles that is greatly underutilized in this country.

Prevalence

Approximately 10 percent of all men have varicoceles - among infertile couples, the incidence of varicoceles increases to 30 percent Highest occurrence in men aged 15-35 As many as 70-80,000 men in America may undergo surgical correction of varicocele annually

Symptoms

Pain - aching pain when an individual has been standing or sitting for long periods of time and pressure builds up on the affected veins. Typically, painful varicoceles are prominent in size.Fertility

Problems - There is an association between varicoceles and infertility. The incidence of varicocele increases to 30 percent in infertile couples. Decreased sperm count, decreased motility of sperm, and an increase in the number of deformed sperm are related to varicoceles. Some experts believe that blocked and enlarged veins around the testes, called varicoceles, cause infertility by raising the temperature in the scrotum and decreasing sperm production.

What are the symptoms of stroke?

The most common symptoms of stroke are:

• Sudden numbness or weakness in the face, arm and/or leg, especially on one side of the body.
• Sudden confusion, trouble speaking or understanding speech.
• Sudden trouble seeing, including double vision, blurred vision or partial blindness, in one or both eyes.
• Trouble walking, dizziness, loss of balance or coordination.
• Sudden severe, headache with no known cause.

If you experience any of these symptoms, even if they go away quickly, seek immediate emergency help.

Every minute counts. Although starved of oxygen, brain tissue does not die in the minutes following a stroke. If blocked blood vessels can be opened within three to six hours, the chances of recovery are greatly improved.

What are the risk factors for stroke?

People who are at higher-than-average risk for stroke include those who have:

High blood pressure.

High blood pressure, or hypertension, puts stress on the walls of blood vessels and can lead to strokes from blood clots or hemorrhage. Half or more of all stroke victims have uncontrolled high blood pressure. Fortunately, this risk factor for stroke can be controlled. Eating a balanced diet, maintaining a healthy weight and exercising regularly can help control high blood pressure. Medications that lower blood pressure also may be prescribed.

High Cholesterol.

High cholesterol can lead to blockage in the carotid artery that takes blood from the neck to the brain. A piece of this plaque can break off and travel to the brain causing a stroke.

Heart disease.

Approximately 15 percent of all stroke victims have a common heart rhythm disorder called atrial fibrillation, that causes the upper chambers of the heart (the atria) quiver instead of beating which allows the blood to pool and clot. If a clot breaks off and enters the blood stream to the brain, a stroke will occur.

Atherosclerosis.

When the carotid arteries, the major blood vessels that supply blood to the brain, become clogged with atherosclerotic plaque, the risk for stroke goes up. Personal history of stroke or TIA. People who have already suffered a stroke or TIA are at increased risk of having another. Modifying risk factors for stroke, including lifestyle changes (e.g. exercise, stop smoking), medications and/or other treatments can reduce this risk.

Lifestyle risk factors.

Smoking, excessive alcohol consumption and being overweight are all significant risk factors for stroke. High cholesterol can lead to blockage in the carotid artery that takes blood from the neck to the brain. A piece of this plaque can break off and travel to the brain causing a stroke.

Age, gender and race.

The risk of stroke goes up with age, with two-thirds of all strokes occurring in individuals 65 years or older. Twenty-eight percent of stroke occur in people under the age of 65. Males have a slightly higher risk than females although more women die from them. African Americans are at a much higher risk in part because they are at increased risk for obesity, high blood pressure and diabetes which increase the risk for stroke. Family history of stroke or TIA. If others in your family have suffered stroke, you may be at higher risk. Regular physical exams, lifestyle changes and medical treatments may reduce this risk.

Diabetes.

People with diabetes are at increased risk for stroke, although keeping diabetes under control with diet and/or medication may help to decrease the risk.

Sickle Cell Anemia.

Sickle cell anemia makes red blood cells less able to carry blood to the body's tissues and organs, as well as stick to the walls of the blood vessels which can block arteries to the brain causing a stroke. Hyper-homocysteinemia. Elevated homocysteine levels in the blood have been identified as a risk factor for heart attack and stroke that may be as important as high cholesterol. Homocysteine is a by-product of the process that metabolizes methionine, an amino acid essential in human nutrition.

Is there more than one type of stroke?

There are two types of stroke:

Blood clots that block the artery are ischemic (is-KEM-ik) strokes and the most common type, causing between 70-80 percent of all strokes.

When a blood vessel ruptures, it causes a bleeding or hemorrhagic (hem-o-RAJ-ik) stroke. Such strokes are usually the result of a ruptured blood vessel or an aneurysm?a weakened area of a blood vessel that bulges or balloons out. Sometimes, abnormal tangles of blood vessels in the brain, called arteriovenous malformations (AVM) can rupture and cause a hemorrhagic stroke. Approximately 20 percent of strokes are hemorrhagic. This is the most common type of stroke in young people.

There are also "mini-strokes" known as TIA's (transient ischemic attacks). People who have one TIA are likely to have another one. TIAs cause brief stroke symptoms that go away after a few minutes or hours. People often ignore these symptoms, but they are an early warning sign and 35 percent of those who experience a TIA will have a full blown stroke if left untreated. TIAs should be taken as seriously as stroke.T

he leading cause of stroke and TIA is carotid artery disease (CAD). In CAD, a substance called plaque builds up over time in the carotid arteries, the large blood vessels on either side of the neck that supply blood to the head and brain. The buildup of plaque is a silent disease, until small particles break away and are carried to smaller arteries, where they block the flow of blood. The nature and severity of symptoms depend on how large an area of the brain is affected and whether the blood supply to the brain is completely or partially blocked.

What causes a stroke?

A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is blocked by a clot or bursts, causing the brain to starve. If deprived of oxygen for even a short period of time, the brain nerve cells will start to die. Once the brain cells die from a lack of oxygen, the part of the body that was controlled by that dead (infracted) part of the brain will malfunction often causing paralysis, numbness, loss of vision, loss of speech or even coma and death.

Do you have any additional information on strokes?

www.sirweb.org/patPub/stroke.shtml

Stroke is the third leading cause of death in the United States behind high blood pressure and cancer. Every 45 seconds someone in the United States has a stroke and every three minutes someone dies from a stroke. In the U.S. alone, an estimated 600,000 individuals will suffer a new or recurrent stroke each year -- 160,000 will die. More than one million American stroke survivors struggle with serious disabilities, including loss of speech and/or language problems, weakness or paralysis, loss of balance or coordination, and confusion and memory loss. All are common impairments in the aftermath of a stroke.

Once it was believed that little could be done to treat stroke. Now we know that if a stroke victim receives emergency care within the first three to six hours of the first symptom, the disabling, long-term effects of stroke may be avoided or greatly reduced. Unfortunately, many people do not recognize the warning signs of stroke or do not know that immediate emergency care can greatly improve their chance of recovery. Studies show that the average person waits 13 hours after experiencing the first symptoms of stroke before seeking medical care, and 42 percent of patients wait as long as 24 hours. It is critical to recognize the symptoms of stroke and seek immediate emergency attention.