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Fig. 1. Biopsy of a pancreatic lesion. a 42-year-old female patient after subtotal pancreatoduodenectomy for pancreatic cancer and recurrent symptoms showing a mass in the retroperitoneal space. b A usable position was chosen and a grid was placed to plan and mark the potential pathway for biopsy. c A 22 G needle was advanced into the lesion and an aspiration biopsy was performed. Cytologic examination proved recurrent pancreatic cancer

Fig. 2. Abscess drainage in 65-year-old patient with diverticulitis. a Massive swelling of the sigmoid due to inflammation and diverticula. b A nonseptated collection close to the sigmoid is seen. c After needle puncture of the collection that proved abscess formation, a guidewire was inserted into the abscess. d In an over-the-wire technique, a 12 F draining catheter was inserted into the abscess. e After evacuation of pus and debris, the collection was refilled by diluted contrast medium to test the stability of the cavity and to exclude extravasation

Fig. 2. Abscess drainage in 65-year-old patient with diverticulitis. a Massive swelling of the sigmoid due to inflammation and diverticula. b A nonseptated collection close to the sigmoid is seen. c After needle puncture of the collection that proved abscess formation, a guidewire was inserted into the abscess. d In an over-the-wire technique, a 12 F draining catheter was inserted into the abscess. e After evacuation of pus and debris, the collection was refilled by diluted contrast medium to test the stability of the cavity and to exclude extravasation

Tumor Ablation

Many tumor ablation techniques are currently performed in liver lesions using lasers, radiofrequency ablation (RFA) and ethanol. They are applied to primary hepatic malignancies and metastatic disease. In patients with hepatocellular carcinoma (HCC), percutaneous ablation is considered the best treatment option when surgical resection or liver transplantation is not suitable for patients with Child-Pugh class A or B; cirrhosis; a single, nodular-type HCC smaller than 5 cm; or as many as three HCC lesions, each smaller than 3 cm. Recent studies have shown that RFA can achieve more effective local tumor control than ethanol injection and with fewer treatment sessions. In a randomized trial, local recurrence-free survival rates were significantly higher in patients who received RFA than in those treated by ethanol injection (one, two, and three year survival rates were 93%, 81%, and 74% in the RFTA group, 88%, 66%, and 51% in the PEI group; one- and two-year local recurrence-free survival rates were 98% and 96% in the RF group and 83% and 62% in the PEI group, respectively [univariate p =.002]). In a univariate analysis, tumor-dependent factors with significantly less local recurrences were smaller size, neuroendocrine metastases, nonsubcapsular location, and location away from large vessels. Treatment allocation was confirmed as an independent prognostic factor by multivariate analysis. In the multivariate analysis, significantly less local recurrences were observed for small size (p <

0.001) tumors. Preliminary reports have shown that RFA performed after balloon catheter occlusion of the hepatic artery, transarterial embolization, or chemoem-bolization results in increased volumes of coagulation necrosis, thus enabling successful destruction of large HCC lesions. However, for the time being, laser and ra-diofrequency therapy can be used to treat only lesions with a maximum diameter of 5 cm. However, these techniques are developing rapidly. There is little experience in ablation of renal tumors. Ablation of renal cell carcinoma has been performed either in patients with a single kidney or with serious contraindications to surgery. Percutaneous ablation needs to be balanced against other minimally invasive techniques such as la-paroscopic kidney removal or partial nephrectomy.

Both in renal and hepatic tumor ablation, some patients, especially those with hypervascularized tumors, may profit from a combined approach with both ablation and transarterial embolization.

Biliary Interventions

As an alternative to endoscopic procedures, percutaneous drainage and stenting of biliary ducts can be performed. The indication is obstructive jaundice due to bile duct tumors, metastatic disease to lymph nodes in the hepato-duodenal ligament or pancreatic tumors. In Klatzkin type tumors at the hepatic duct bifurcation, drainage and stent-ing of both lobes of the liver is required (Fig. 3). Self-expanding metal stents have proven in randomized trials to

Fig. 3. Biliary obstruction due to metastases of pancreatic carcinoma. a CT of pancreatic carcinoma before surgery. b CT one year after surgery (tumor resection) demonstrating obstructed common hepatic duct due to tumor recurrence at the liver hilum. c PTCD showing obstruction of the bilioenteric anastomosis. d Bilateral stenting of the obstructed hepatojejunostomy

Fig. 3. Biliary obstruction due to metastases of pancreatic carcinoma. a CT of pancreatic carcinoma before surgery. b CT one year after surgery (tumor resection) demonstrating obstructed common hepatic duct due to tumor recurrence at the liver hilum. c PTCD showing obstruction of the bilioenteric anastomosis. d Bilateral stenting of the obstructed hepatojejunostomy show longer patency rates than plastic tubes. Drainage of the gallbladder is rarely performed, but sometimes helpful in multimorbid patients.

Gastrointestinal and Colonic Stent Placement

As a palliative approach or a temporary solution in patients with obstructing tumors of the duodenum or the colon, metallic stents are placed as an alternative to surgical decompression.

Percutaneous Gastrostomy/Ileostomy

Several kits exist that enable radiologists to perform gas-trostomy and ileostomy using a percutaneous approach. Indications are in patients with long-term swallowing disorders due to tumors or neurological deficiencies.

Newer Procedures

As a palliative approach to treat ascites, either percutaneous creation of a Denver shunt or percutaneous port-catheter placement - to allow repeat and ease paracentesis have been described.

Vascular Interventions Acute Arterial Occlusion

If acute occlusion of the abdominal aorta or branch vessels occurs, two causes have to be considered:

• Embolization

Embolization

Embolization is most common in elderly patients with atrial fibrilation, a history of myocardial infarction and aortic aneurysm. Embolization from the heart or thoracic aorta may cause acute subtotal or total occlusion of the celiac, superior mesenteric (SMA), inferior mesenteric artery (IMA) or the renal arteries. The most common causes of embolization are:

• Atrial fibrillation

• Thoracic aortic aneurysm

• Myocardial infarction with mural thrombus formation

• Advanced aortic arteriosclerosis

• Perforating arteriosclerotic ulcer

• Hypercoagulability syndrome.

The symptoms of acute ischemia are dependent on the involved vascular territory. Embolization to the liver or spleen may cause acute right or left upper abdominal pain. Acute mesenteric ischemia typically causes severe abdominal pain and bowel paralysis. Embolization to the kidney causes flank pain, hematuria and hypertension. In any case, severe elevation of lactose dehydrogenase (LDH) points to the ischemic nature of the acute pain. In case of complete ischemia without a sufficient collateral circulation, the warm ischemic time tolerated by the abdominal organs is less than six hours. Therefore, acute diagnosis and therapy are mandatory.

The primary diagnosis is performed by CT with contrast enhancement (CM 300 mgJ/ml; 4 ml/sec; total bolus volume 80-120 ml; bolus care technique with 20-40 second delay; 2 mm collimation; pitch 2; reconstruction interval 1 mm). The obstructing embolus and the is-chemic territory can be visualized in the arterial phase. In the delayed phase, a residual perfusion through collateral arteries may be demonstrated.

Interventional treatment with a thrombectomy device and/or local intra-arterial fibrinolysis with recombinant tissue plasminogen activator (rt-PA) (10 mg loading dose, 5 mg/hr infusion dose) or urokinase (250 000 IU loading dose, 100 000 IU/hr infusion dose) together with a G IIb/IIIa antagonist (Aciximab: 0.25 mg/kg loading dose, 0.125 mg/kg/hr infusion dose) is one option. The other option is surgery, which may be faster and also enables inspection and, if necessary, resection of ischemic organs.

Dissection

Dissection is most common if there is a history of trauma, chronic severe hypertension, or a connective tissue disease such as Marfan syndrome or Ehlers-Danlos syndrome. Acute type A and B aortic dissection may cause dynamic compression of the original lumen of the aorta by the pressurized false lumen. This can cause acute ischemia of liver/spleen, bowel and kidneys. The dissection plane may also run into one of the organ arteries causing obstruction of the true lumen. There are a number of in-terventional treatment options. In case of a dynamic compression of the true aortic lumen, occlusion of the proximal entry into the false lumen with an aortic stentgraft will cause decompression of the false lumen and results in reopening of the true lumen of the aorta and the side branches. In case of a static compression due to a side-branch dissection, stent placement in the true lumen of the organ artery will cause reconstitution of organ perfusion. In case of organ perfusion through the false lumen, balloon fenestration of the intimal flap will re-establish flow into the malperfused territory.

Chronic Arterial Occlusive Disease

In young patients, causes of chronic arterial occlusion include:

• Fibromuscular disease (FMD)

• Takayasu arteritis

• Recklinghausen neurofibromatosis.

The primary cause of chronic arterial occlusive disease in elderly patients is arteriosclerosis.

Mesenteric Artery Stenosis

Between the three large mesenteric arteries (celiac artery, SMA, IMA), there are many collateral pathways, including:

• Pancreatico-duodenal arteries

• Arc of Buehler between celiac artery and SMA

• Marginal artery Drummond between SMA and IMA. Therefore, an obstruction of at least two mesenteric arteries is necessary to cause ischemic symptoms. The typical clinical symptom is the angina abdominalis with:

The primary diagnosis is made by aortic arteriography in a lateral projection by either intra-arterial catheter an-giography, CT angiography, or MR angiography.

Interventional treatment is percutaneous transluminal angioplasty (PTA) with or without secondary stent placement of at least one of the obstructed arteries (Fig. 4).

Celiac Trunk Stenosis

Chronic obstruction may remain asymptomatic because of the collateral pathways through gastroduodenal and pancreatic arteries from the superior mesenteric artery. Causes are arteriosclerotic plaque, compression by the arcuate ligament or carcinoma of the pancreas.

Superior Mesenteric Artery Stenosis

Post prandial abdominal pain, called 'angina abdomi-nalis' occurs only if two or all three gastrointestinal arteries are obstructed. Causes for SMA obstruction are arteriosclerosis, fibromuscular disease (FMD), Takayasu arteritis, pancreatic carcinoma or chronic pancreatitis.

Inferior Mesenteric Artery Stenosis

Obstruction of the IMA is most commonly observed in patients with advanced atheromatosis or partially thrombosed abdominal aortic aneurysm. Due to the collateral circulation through the arc of Riolan and the marginal artery, IMA obstruction normally remains asymptomatic.

Renal Artery Stenosis

Renal artery stenosis (RAS) may cause hypertension and/or renal insufficiency. Acute onset of the clinical

Fig. 4. Balloon angioplasty and stenting in a patient with mesenteric angina. A 77-year-old female patient with recurrent and constant pain after eating, a Aortic angiography shows ^^^ absence of superior mesenteric artery and small inferior mesenteric with a not well-developed Riolan's arch. The celiac artery, however, is present. b Selective angiography shows tight stenosis of the common hepatic artery. c After stent placement patency was restored. The symptoms disappeared the next day symptoms and repeated flash pulmonary edema are suggestive for a renal artery stenosis. The etiology can be:

• Arteriosclerosis in 65-75% of cases

- patients > 50 years

- proximal 2 cm of renal artery

- atherosclerotic changes of aorta

- bilateral in 30%

- patients of 15-30 years

- middle to distal renal artery including branches

- bilateral involvement in 50-70%

- 'string of beads' appearance, aneurysms, dissections

- no aortic disease

• Takayasu arteritis

• Mid aortic syndrome

• Morbus Recklinghausen

• Post radiation therapy.

The correct algorithm for the diagnosis of a renal artery stenosis is not established.

Color duplex ultrasound is a noninvasive test but is a complex examination and requires an experienced operator. An increased peak systolic velocity of more than 200 cm/s, a renal-to-aortic ratio of peak systolic velocity of more than 3.5, an intrastenotic turbulence and a flattened pulse wave in the periphery (pulsus tardus) are diagnostic criteria for a renal artery stenosis. The sensitivity of color duplex sonography for detection of RAS of more than 70% is 72-92%. Color duplex US with an an-giotensin-converting enzyme (ACE) inhibitor provides a positive predictive value of 67-95% for cure or improvement after revascularization.

A nuclear scan (renal scintigraphy with technetium-99m mercaptoacetyltriglycine (MAG3) or Tc-99m dieth-

ylenetriaminepentaacetic acid [DTPA]) with an ACE inhibitor (captopril 25 mg) shows a delayed wash-out of the tracer within the post stenotic kidney. However, in bilateral disease and in chronic ischemic nephropathy, the lateralization of the tracer is less evident. In a selected population with a clinical high risk for RAS, the sensitivity for detection of a unilateral RAS of more than 70% is 5196% (mean 82%). Its positive predictive value for a RAS with improvement of hypertension after revascularization is 51-100% (mean 85%). However, scintigraphy is much less sensitive in patients who are unselected, or have bilateral disease, impaired renal function, urinary obstruction or chronic ACE inhibitor intake.

Newer tests are gadolinium-enhanced magnetic resonance angiography (MRA) and spiral CT angiography (CTA). For a state-of-art MRA, high field-strength systems with high performance gradients are necessary for breath-hold 3D spoiled gradient-echo imaging with short repetition time (TR) and echo time (TE). Intravenous administration of gadolinium contrast material in a double dose (0.2 mmol/kg; 2 ml/sec flow rate), a central k-space readout and background subtraction are additional techniques to improve signal-to-noise ratio and spatial resolution. The sensitivity to detect a RAS of more than 50% is more than 95% with MRA. The main limitations of renal MRA are evaluation of small, accessory renal arteries and branch vessels, the presence of stents and a tendency to overestimate moderate stenoses.

CTA of the renal arteries has a sensitivity of more than 95% to detect RAS and accessory renal arteries. For a high quality opacification of the renal arteries and to avoid renal vein overlap, a correct bolus planning is mandatory (density measurement during bolus rise, flow 4 ml/s, total volume 80-120 ml - multidetector scanners need less contrast). A short breath-hold acqui sition, collimation (1-2 mm), pitch (1.5-6, depending on single or multidetector technology) and overlap of reconstruction (0.5-0.75) are important parameters for the spatial resolution of the study. Curved planar reconstruction (CPR, most useful for stents), volume rendering and maximum intensity projection (MIP) are used for 3D imaging (Fig. 5).

Intra-arterial catheter arteriography together with pressure gradient measurement is still the 'gold standard' for evaluation of a RAS.

The revascularization technique of choice is renal PTA without or with stent placement (Fig. 5). Aorto-renal bypass surgery is indicated only if PTA fails. In a recently published meta-analysis, renal arterial stent placement proved to be technical superior and clinically comparable to renal PTA alone. The technical success rate of stent versus PTA was 98% versus 77% and the restenosis rate was 17% and 26%, respectively (p < 0.001). In hypertension the cure rate of PTA stent versus was 10% versus 20%, the rate of improvement was 53% and 49%, respectively. In renal insufficiency, the rate of improvement was 38% versus 30%, of stabilization 41% and 38%, respectively. The complication rate was 11-13% (95% CI 619%), the in-hospital mortality rate, 1%. In a randomized study comparing stents to PTA in ostial stenoses, the technical success rate was 88% versus 57% and the six month primary patency rate was 75% versus 29%, respectively. Two randomized trials comparing the effect of PTA and drug therapy on renal hypertension did not reveal a significant benefit of PTA over continuous drug therapy. However, in the Dutch study, PTA patients required only 2.1 versus 3.2 daily drug doses (p < 0.001) and 22/53 patients in the drug group had to be switched to the PTA group because of persistent hypertension or deterioration of renal function.

Aneurysms

Abdominal Aortic Aneurysm (AAA)

The incidence of AAA in European adults 60 years and older is 2.5%. Up to 10% of patients with symptomatic

Fig. 5. Patient with abdominal aortic aneurysm and renal artery stenosis. a CTA with MIP reconstruction. b Aortography before stentgraft placement. c After stentgraft implantation. d Renal artery stenting after stentgraft implantation. e After renal stenting. f Control CTA after renal artery stent and AAA stentgraft

Fig. 5. Patient with abdominal aortic aneurysm and renal artery stenosis. a CTA with MIP reconstruction. b Aortography before stentgraft placement. c After stentgraft implantation. d Renal artery stenting after stentgraft implantation. e After renal stenting. f Control CTA after renal artery stent and AAA stentgraft peripheral arterial disease (PAD) die from rupture of aneurysm disease.

Currently, the standard treatment is open surgery. However, endovascular implantation of stentgrafts is a new, emerging technique which may replace open surgery in the future. Since the first clinical implant of a tube stentgraft in 1990, many different stentgraft designs have been developed and tested in feasibility studies. Most recently, randomized studies (EVAR 1 Trial, Dream Trial) compared the results of open versus endovascular repair. In the EVAR Trial the 30 day mortality in the EVAR group was 1.7% (9/531) versus 4.7% (24/516) in the open repair group (p = 0.009). Four years after randomization, all-cause mortality was similar in the two groups (about 28%; p = 0.46), although there was a persistent reduction in aneurysm-related deaths in the EVAR group (4% versus 7%; p = 0.04).

Indications

The indications for endovascular treatment of AAA are currently the same as for open surgery:

• Symptomatic aneurysm (i.e., embolization, pain, ureteral compression)

Specific clinical indications for the endovascular approach may be:

• Hostile abdomen

• Inflammatory aneurysm, horse-shoe kidney.

The anatomic indications for stentgraft treatment are:

• Infrarenal neck > 15 mm in length

• Infrarenal neck without thrombus or severe calcification

• Angulation of the infrarenal neck < 65°

• Patent celiac trunk and SMA

• Stent graft diameter 10% more than neck diameter

• Iliac artery without thrombus or severe calcification

• More than 15 mm overlap within the iliac arteries. Endovascular implantation of stentgrafts can be performed under general, epidural or local anesthesia. The use of epidural anesthesia is a major advantage in elderly and high-risk patients.

Stentgraft Designs

Stentgrafts have a self-expandable stent structure covered by an ultrathin polyester or ePTFE fabric. Currently, only bifurcated stentgrafts are used for the treatment of AAA.

Imaging Before Stentgraft Implantation

Contrast-enhanced spiral CT with multiplanar reconstruction (MPR) or MIP reconstruction is the most important examination before stentgraft implantation (Fig.

5). The diameter of the landing zones (infrarenal neck, iliac arteries), the maximum diameter of the aneurysm, thrombus, and calcifications can be well depicted by CT.

Complications

The most common complication of stentgraft implantation is incomplete exclusion of the aneurysm with remaining pressurization of the aneurysm sack through an endoleak. White and May proposed a classification of primary (< 30 days) and secondary (> 30 days) endoleaks:

• Type 1: direct perfusion through the proximal (in-frarenal) or distal (iliac) anastomosis

• Type 2: retrograde perfusion through branch vessels (lumbar arteries, IMA, accessory renal artery)

• Type 3: midgraft leak due to disintegration of the stent-graft (disconnection of the second iliac limb, fabric erosion)

• Type 4: fabric porosity

Results

The largest database currently available is the Eurostar registry, which has more than 7000 patients. At completion angiography, endoleaks were demonstrated in 15.8% of patients. Type 1 endoleaks were observed in 4.1%, type 2 reperfusion endoleaks were observed in 9.8% and type 3 leaks in 1.9% of patients. Technically successful stentgraft placement was achieved in 99% of patients. Conversion to open surgery was required in 0.7%. The inhospital mortality rate was 2.6%.

Life-table analysis revealed a survival rate of 92%, 84%, and 77% at 1, 3, and 5 years, respectively. The freedom from persistent endoleaks was 84%, 75%, and 69% at 1, 3, and 5 years, respectively. However, type 2 en-doleaks turned out to be rather benign, not causing rupture in the vast majority of cases. 98% of the patients were free from aneurysm rupture at 5 years.

Visceral Artery Aneurysm

Aneurysms of the celiac trunk, splenic artery, hepatic artery, gastroduodenal artery and superior mesenteric artery are caused by arteriosclerosis, arteritis, periarterial inflammation such as pancreatitis, trauma and soft tissue diseases such as Marfan and Ehlers-Danlos syndrome. An aneurysm more than 2.5 cm in diameter should be considered to prevent rupture. Meticulous imaging, including selective catheter angiography and 3D imaging with CTA or MRA is necessary before surgery or en-dovascular treatment. The endovascular options are em-bolization and exclusion with a stentgraft.

Renal Artery Aneurysm

The causes of renal artery aneurysm are arteriosclerosis, systemic vasculitis such as polyarteritis nodosa or lupus erythematosus, FMD, soft tissue disorders and trauma. Arteriosclerotic and large aneurysms are usually calcified. Potential rupture and chronic embolization are the indications for treatment. Bypass surgery, coil embolization and stentgraft implantation are the therapeutic options.

Tumor Embolization

Tumor embolization techniques vary from palliative em-bolization in bleeding genitoureteral tumors, chemoem-bolization techniques in hypervascularized hepatic neoplasms (in particular HCC), to definite treatment of benign lesions such as uterine fibroids. In the liver, tumor embolization is mainly used for inoperable HCC with still acceptable liver function (Child-Pugh A and B). The classical treatment is chemoembolization with doxoru-bicine mixed with lipiodol sometimes in combination with a temporary blockade of the hepatic artery by Gelfoam or other embolization particles. In randomized trials, chemoembolization of unresectable HCC has shown to be superior to supportive treatment only. New techniques include doxorubicine-loaded particles as an alternative embolization agent for HCC, chemoperfusion with different cytotoxic agents for metastatic disease and intrahepatic radiation by radioactive particles directly injected into the hepatic arteries.

Treatment for Bleeding Complications

Bleeding in the abdomen may occur due to iatrogenic causes, particularly in the kidneys and the liver after percutaneous interventions, trauma and tumor.

Frequent and typical locations are renal arteriovenous fistulas due to nephrostomy (Fig. 6) or biopsy, laceration of the hepatic arteries by percutaneous manipulations, psoas and pelvic bleeding due to traumatic arterial injury and also post partum. Temporary occlusion of the uterine artery can then be a valid alternative to emergency hysterectomy in patients with intractable bleeding due to an atonic uterus.

In other locations, type, source and location of the bleeding determine the method that is used to safely interrupt extravasations.

Venous Interventions

Transjugular Intrahepatic Portocaval Shunt (TIPS)

TIPS was introduced into clinical medicine at the end of the eighties. In the meantime, a standardized technique has become available that allows safe application of this artificial connection. The introduction of stentgrafts instead of bare stents led to an improved patency of the shunt tract. Stentgrafts are indicated in acute and chronic bleeders, in patients with liver cirrhosis and esophageal varices, and patients with intractable ascites. Its risks are liver failure from shunted blood volume, and encephalopathy. Endoscopic techniques to treat varices are competitive techniques in bleeders, but in some patients with ascites there are few alternatives. In patients with acute or subacute Budd-Chiari syndrome, TIPS can be a life-saving procedure and help to overcome the acute phase, but is burdened by a relatively high rethrombosis rate.

Tract reobstruction requires a number of different techniques for debulking the stenosed or thrombosed stents, including mechanical thrombectomy, atherectomy, PTA, re-stenting or stent graft implantation.

Fig. 6. Iatrogenic perirenal bleeding after percutaneous nephrostomy. a Selective left renal angiography in a 73-year-old male who suffered from massive bleeding from a nephrostomy catheter that was placed the same day. Angiographically, laceration of the lower pole artery is seen at a relatively central location, b Superselective angiography of the segmental artery clearly shows the bleeding site. c After combination of coil placement and glue embolization, the leakage stopped. Due to the central position, a part of the kidney had to be sacrificed

Fig. 6. Iatrogenic perirenal bleeding after percutaneous nephrostomy. a Selective left renal angiography in a 73-year-old male who suffered from massive bleeding from a nephrostomy catheter that was placed the same day. Angiographically, laceration of the lower pole artery is seen at a relatively central location, b Superselective angiography of the segmental artery clearly shows the bleeding site. c After combination of coil placement and glue embolization, the leakage stopped. Due to the central position, a part of the kidney had to be sacrificed

Interventions in the Portal and Mesenteric Veins

Besides TIPS application, a transjugular approach can be used for transjugular liver biopsy in patients with ascites or bleeding disorders, or as an entrance to the portal system, for example, to treat segmental hypertension due to stenoses that are located proximally to the portal vein, such as the mesenteric or splenic vein. Also recanaliza-tion of thrombotic portal occlusions may be treated via the transjugular approach to create a conduit that allows outflow from the recanalized vein.

The portal vein may also be accessed in a transhepat-ic fashion for selective blood sampling or venous re-canalization. An intervention of increasing importance is preoperative embolization of the right portal vein in order to induce hypertrophy of the left hepatic lobe prior to extended right hemihepatectomy.

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