1. Interventional procedures in
Hepatobiliary system

2. 1.Oncologic therapeutic
procedures :
 Tumor Embolization : Method that promotes
tumor destruction by embolization of its
suppliers vessels.
◦ Hepatic radioembolization
 Tumor Ablations : Percutaneous local tumor
destruction by using a device to cause cell
death.

3. 2.Vascular Interventions
 Trans-jugular intra hepatic portosystemic
shunt (TIPS)
 Transjugular liver biopsy (TJLB)

4. 3.Biliary interventions :
 Percutaneous or endoscopic (ERCP)
 Percutaneous transhepatic cholangiography
(PTC)
 Percutaneous transhepatic biliary drainage
(PTBD)
 Percutaneous cholecystostomy (PC)

5. 4.Others
Percutaneous liver biopsy
 Ultrasound guided
 CT guided
Percutaneous collections drainage
 Ultrasound guided
 CT guided

6. Liver CancerTreatments
 Tumors need a blood supply, which they actively
generate, to feed themselves and grow.
 In treating cancer patients, interventional
radiologists attack the cancer tumor from inside
the body without medicating or affecting other
parts of the body by using embolization and
radiofrequency heat.

7.  Chemoembolization delivers a high dose
of cancer-killing drug (chemotherapy)
directly to the organ while depriving the
tumor of its blood supply by blocking, or
embolizing, the arteries feeding the tumor.

8.  In treating cancer patients, interventional
radiologists use embolization to cut off the
blood supply to the tumor (embolization),
deliver radiation to a tumor
(radioembolization), or combine this technique
with chemotherapy to deliver the cancer drug
directly to the tumor (chemoembolization).

9.  Chemoembolization is a minimally
invasive treatment for liver cancer that
can be used when there is too much
tumor to treat with radiofrequency
ablation (RFA), when the tumor is in a
location that cannot be treated with RFA,
or in combination with RFA or other
treatments.

10.  Using imaging for guidance, a tiny catheter
up the femoral artery in the groin into
the blood vessels supplying the liver
tumor.

11. Chemoembolization
 The embolic agents keep the
chemotherapy drug in the tumor by
blocking the flow to other areas of the
body.This allows for a higher dose of
chemotherapy drug to be used, because
less of the drug is able to circulate to the
healthy cells in the body.

12.  Chemoembolization is a palliative, not a
curative, treatment. It can be extremely
effective in treating primary liver cancers,
especially when combined with other
therapies.

13. Catheter is placed via a transfemoral approach with
tip within the selected hepatic artery

14. SIR-Sphere size is small enough to gain entry into
tumor nodules but too large to pass through the end
capillary bed into the venous circulation
Tumor vessels 25μm -75μm
End arterioles 8 μm
SIR-Spheres mean diameter 35 μm

20. Yttrium-90 Radioembolization
 Radioembolization is very similar to
chemoembolization but with the use of
radioactive microspheres.This therapy is
used to treat both primary and metastatic
liver tumors.

21.  This treatment incorporates the
radioactive isotopeYttrium-90 into the
embolic spheres to deliver radiation
directly to the tumor. Each sphere is
about the size of five red blood cells in
width.

22.  These beads are injected through a
catheter from the groin into the liver
artery supplying the tumor.The beads
become lodged within the tumor vessels
where they exert their local radiation that
causes cell death

23.  This technique allows for a higher, local
dose of radiation to be used, without
subjecting healthy tissue in the body to
the radiation.

24.  Radioembolization is a palliative, not a
curative, treatment-but patients benefit by
extending their lives and improving their
quality of life. It is a relatively new therapy
that has been effective in treating primary
and metastatic liver cancers. It is
performed as an outpatient treatment.

25. TIPS
 Portal hypertension condition in which the
normal flow of blood through the liver is
slowed or blocked by scarring (cirrhosis) or
other damage (e.g. hepatitis). Patients with
the condition are at risk of internal bleeding
or other life-threatening complications.
Transjugular intrahepatic portosystemic
shunt (TIPS) formation is a minimally-
invasive treatment to alleviate this impaired
blood flow.

26. Indications
1. Prevention of variceal bleeding
2. Acute bleeding of esophageal varices that is
refractory to medical therapies
3. Esophageal variceal rebleeding
4. Bleeding from gastric varices
5. Prevention of bleeding from portal
hypertensive gastropathy
6. Ascites due to cirrhosis
7. Budd-Chiari syndrome
8. Veno-occlusive diseases

27. Absolute contraindications
1. Congestive heart failure
2. Multiple hepatic cysts
3. Uncontrolled systemic infection or
sepsis
4. Unrelieved biliary obstruction
5. Severe pulmonary hypertension.

28. Relative contraindications
1. Hepatoma
2. Obstruction of all hepatic veins
3. Portal vein thrombosis
4. Thrombocytopenia of less than
20,000/cm(3)
5. Severe coagulopathy
6. Moderate pulmonary hypertension

29. TIPS
• A catheter is placed in the right
jugular vein
• The catheter is threaded through
the superior and inferior vena cava
to the hepatic vein
• Wall of the hepatic vein is
punctured and the needle is
directed across an approximate 2
inch gap to the portal vein
• Successful passage into the portal
vein is determined by the pattern
of dye injected through the
catheter

30. TIPS
• A guide wire is
threaded through
the needle to
maintain the
passage between
the hepatic and
portal veins

31. TIPS
• A balloon may be used
across the passage to
widen the holes in the
vessel walls and the
passage through the
liver tissue

33. Biliary interventions :
 Percutaneous or endoscopic (ERCP)
 Percutaneous transhepatic cholangiography
(PTC)
 Percutaneous transhepatic biliary drainage
(PTBD)
 Percutaneous cholecystostomy (PC)

34.  There is a 5-15% incidence of retained stones
after cholecystectomy
 Associated with increased risk of recurrent
biliary obstruction, pancreatitis, and cholangitis.
 Benign/malignant strictures.

36. ERCP
The diagnostic procedure of choice for
abnormalities of the biliary and pancreatic
ducts offers options of intervention:
 Stone extraction
 Sphincterotomy
 Placement of stents

37.  A side viewing endoscope is advanced
into the descending duodenum the papilla
ofVater is identified and cannulated
contrast is injected to visualize the
pancreatic duct and biliary duct systems

38. Causes for ERCP failure include:
 Upper GI stricture/stenosis
 Complete ductal obstruction limiting
retrograde filling
 Postsurgical biliary-enteric fistula
 Technical failure
MRCP is an effective alternative when
ERCP is unsuccessful

41. PercutaneousTranshepatic
Cholangiography
 Old reliable
 Accurate technique for defining the site of
obstruction
 Provides option of tissue biopsy and/or
intervention with drain or stent
 Has been largely replaced by non-invasive
techniques

42. Indications
 Failed ERCP / ERCP not feasible (e.g.
patients with gastrojejunostomy)
 Biliary system delineation in presence of
intra and extrahepatic biliary calculi
 To identify obstructive cause of jaundice; and
differentiate from medically treatable cause
 Anatomic evaluation of complications of
ERCP
 Delineating bile leaks

43. Contraindications
 Bleeding diathesis
 Gross ascites

44. Technique
◦ Standard technique:Thin needle puncture in
ninth or tenth intercostal space
◦ Contrast injected during slow withdrawal of
the needle under fluoroscopic guidance
◦ When duct placement confirmed, additional
injection
◦ Films taken in AP, right and left oblique

46. Surgical resection offers potential for cure
but is rarely possible
Palliation alternatives:
1. Surgical bypass
2. Percutaneous drainage
3. Endoscopic or percutaneous stent
placement

47.  Three types of drains:External – does not
cross obstruction, drains percutaneously
 Internal-external – bile in obstructed
segment enters through the side holes of the
catheter and emerges beyond the
obstruction; the external segment can be
capped
 Internal – drains only into enteric system

49. Percutaneous cholecystostomy
 Image-guided placement of drainage
catheter into gallbladder lumen.This
minimally invasive procedure can aid
stabilization of a patient to enable a more
measured surgical approach with time for
therapeutic planning.

50. Indications
 poor surgical candidate/high risk patients
with acute calculous or acalculous
cholecystitis.
 unexplained sepsis in critically ill patients
(Diagnostic for cholecystitis as etiology of
sepsis if clinical improvement after
cholecystostomy).
 access to or drainage of biliary tree
following failed ERCP and PTC.

51. Contraindications
Absolute contraindications
 usually none
Relative contraindications
 bleeding diathesis: all attempts should be
made to correct coagulopathy.
 ascites
 gallbladder tumor that might be seeded
 gallbladder packed with calculi preventing
catheter insertion

53. Thanks