Textbook of Interventional Radiology (Jan 1, 2025)_(9819796008)_(Springer).pdf

Preface Acknowledgments Contents About the Editor Part I: General Considerations 1: History of Interventional Radiology 1.1 Introduction 1.2 Early Beginnings 1.3 Catheter-Directed Thrombolysis 1.4 Stents 1.5 Coronary Angiography 1.6 Acute Gastrointestinal Bleeding 1.7 Transjugular Intrahepatic Portosystemic Shunt 1.8 Conclusion References 2: Patient Preparation in Interventional Radiology 2.1 Introduction 2.2 History-Taking 2.3 Examination of the Patient 2.4 Pre-procedure Imaging 2.5 Pre-procedure Investigations 2.6 Assessment of Risk Associated with Iodinated Contrast Use 2.7 Assessment of Bleeding Risk 2.8 Informed Consent 2.9 Anesthesia and Sedation 2.10 Part Preparation 2.11 Antibiotic Prophylaxis 2.12 Antiplatelet Use Prior to Angioplasty and Stent Placement References 3: Image Guidance in Interventional Radiology 3.1 Introduction 3.2 Ultrasonography 3.2.1 Advantages 3.2.2 Indications of USG-Guided Interventions 3.2.3 Limitations 3.3 Fluoroscopy 3.3.1 Indications 3.3.2 Interventional Fluoroscopy 3.3.2.1 Digital Subtraction Angiography 3.3.3 Advantages of DSA Include 3.3.4 Indications of DSA 3.3.5 Limitations of DSA 3.4 Computed Tomography 3.4.1 Advantages of CT-Guided Interventions 3.4.2 Indications 3.4.3 Limitations 3.5 Magnetic Resonance Imaging 3.5.1 Advantages of MRI-Guided Interventions 3.5.2 Indications of MRI-Guided Interventions 3.5.3 Limitations 3.6 Dose Reduction Techniques and Recent Advances 3.6.1 Dose Reduction in Fluoroscopy 3.6.2 Special Considerations of Radiation Protection in Pediatric Population 3.6.3 Remove Anti-scatter Grid 3.6.4 Pulsed Fluoroscopy 3.6.5 Checklist 3.7 Dose Reduction in CT 3.8 Special Considerations in Pregnancy 3.9 Conclusion References 4: Contrast and Drugs in Interventional Radiology 4.1 Introduction 4.2 Pharmaceutical Agents 4.2.1 Contrast Agents 4.2.2 Iodinated Contrast Media (ICM) 4.2.2.1 Basic Chemistry of ICM 4.2.2.2 Types of ICM 4.2.2.3 Post-contrast Acute Kidney Injury and Contrast-Associated Acute Kidney Injury (CA-AKI) Pathogenesis Risk Factors Choice of Contrast Diagnosis Risk Threshold Recommendations for Prevention 4.3 Carbon Dioxide 4.3.1 Indication 4.3.2 Contraindications 4.3.3 Equipment 4.3.4 Preparation 4.3.5 Technique 4.3.6 Complications 4.3.7 Advantages 4.3.8 Disadvantages 4.4 Anticoagulation and Antiplatelet Medications 4.4.1 Thrombolytics 4.4.1.1 Classification First-Generation Thrombolytic Agents Second-Generation Thrombolytic Agents Third-Generation Thrombolytic Agents 4.4.1.2 Contraindications 4.4.1.3 Adverse Effects 4.4.2 Anticoagulants 4.4.2.1 Unfractionated Heparin (UFH) Mechanism Indications 4.4.2.2 Low-Molecular-Weight Heparin (LMWH) Mechanism Indications Special Considerations 4.4.2.3 Warfarin Mechanism Indications Special Considerations 4.4.3 Antiplatelet Drugs 4.4.3.1 Aspirin Mechanism Route and Dose Recommendations 4.4.3.2 Clopidogrel Mechanism Route and Dose Recommendations 4.4.3.3 Glycoprotein IIb/IIIa Inhibitors (GPI) Mechanism Recommendations 4.4.4 Vasodilators 4.4.4.1 Nitroglycerine Mechanism Route and Dose Indications 4.4.4.2 Verapamil Mechanism Route and Dose Indications Contraindications Complications 4.4.5 Vasoconstrictors 4.4.5.1 Mechanism 4.4.5.2 Route and Dose 4.4.5.3 Indication 4.4.5.4 Complications and Adverse Effects 4.4.6 Prothrombotics 4.4.6.1 Mechanism 4.4.6.2 Route and Dose 4.4.6.3 Indications 4.4.6.4 Complications and Contraindications 4.4.6.5 Special Considerations 4.5 Conclusion References 5: Anesthesia in Interventional Radiology 5.1 Introduction 5.2 Pre-procedure Tasks 5.2.1 Overview of Challenges 5.2.2 Equipment and Logistic Organization 5.2.3 Management of Patients During Transport to the IR Suite 5.2.4 Pre-anesthetic Evaluation 5.3 Anesthesia Techniques 5.3.1 Local Anesthesia 5.4 Pediatric IR Procedures 5.5 Anesthesia Considerations 5.6 Type of Anesthesia 5.7 Difficult Airway Management 5.8 Immediate Treatment of Aspiration 5.9 Management of Blood Loss and Deranged Coagulation Parameters 5.10 Considerations for Specific IR Procedures 5.11 Conclusion References 6: Periprocedural Bleeding and Thrombotic Considerations in Interventional Radiology 6.1 Introduction 6.2 Physiology of Hemostasis 6.3 Pre-procedural Workup 6.3.1 Prothrombin Time (PT-INR) 6.3.2 Activated Partial Thromboplastin Time (aPTT) 6.3.3 Viscoelastic Tests 6.4 Bleeding Risk in Interventional Radiology Procedures 6.4.1 Procedure-Related Bleeding Risk 6.4.2 Periprocedural Management of Antiplatelet and Anticoagulant Agents 6.5 Specific Disease Considerations 6.5.1 Chronic Liver Disease 6.5.2 Chronic Kidney Disease 6.5.3 Thrombocytopenia 6.5.4 Disseminated Intravascular Coagulation (DIC) 6.5.5 Malignancy 6.5.6 Patients with Prosthetic Heart Valves 6.6 Bridge Therapy 6.7 Deep Vein Thrombosis (DVT) 6.8 Atrial Fibrillation (AF) 6.9 Coronary Stents 6.10 Conclusion References 7: Embolization in Interventional Radiology 7.1 Introduction 7.2 Role of Pre-embolotherapy Imaging 7.3 Vascular Access and Hardwires 7.4 Embolic Agent Selection 7.5 Technical Pearls for Using Different Embolic Agents [10–13] 7.5.1 Gelfoam Embolization 7.5.2 Coil Embolization 7.5.3 Amplatzer Vascular Plug Embolization 7.5.4 Glue Embolization 7.6 Clinical Applications 7.6.1 Aneurysm and Pseudoaneurysm 7.6.1.1 Endovascular Approach Parent Artery Preservation [16, 17] Stent or Balloon-Assisted Coiling [20, 21] Multi-Layered Flow-Diverting Stents [22] 7.6.1.2 Parent Artery Occlusion Sandwich Technique [19–22] Only Proximal Inflow Embolization [16, 17, 23] 7.6.1.3 Percutaneous Approach [16, 17, 24, 25] 7.6.2 Tumoral Embolization 7.6.3 AVM Embolization 7.6.4 Embolization in Trauma [37, 38] 7.6.5 Special Scenario 7.6.5.1 Provocative Angiography 7.6.5.2 Lower GI Bleeding 7.6.5.3 Hepatic Artery Aneurysm 7.6.5.4 Renal Artery Aneurysm (RAA) 7.6.5.5 Percutaneous Transhepatic or Transplenic Access for Embolization 7.7 Newer Embolizations 7.7.1 Genicular Artery Embolization 7.7.2 Other Transarterial Embolization (TAE) for Chronic Musculoskeletal Pain 7.7.3 Bariatric Artery Embolization (BAE) for Obese Patients 7.8 Conclusion References 8: Hardware for Interventions 8.1 Introduction 8.2 Puncture Needles 8.3 Guidewires 8.4 Sheath System 8.5 Catheters 8.6 Microcatheters 8.7 Embolizing Agents 8.7.1 Gelatin Foam 8.7.2 Autologous Blood Clot 8.7.3 Thrombin 8.7.4 Coils 8.7.5 Vascular Plugs 8.7.6 Particulate Agents 8.7.7 Liquid Embolic Agents 8.8 Detachable Balloons References 9: Balloons and Stents 9.1 Introduction 9.2 Balloons 9.2.1 Basics 9.2.2 Mechanism of Action of Balloons 9.2.3 Compliance of a Balloon 9.2.4 Semi-Compliant Balloons (Fig. 9.2) 9.2.5 Non-compliant Balloons (Fig. 9.3) 9.2.6 Composition of Balloons 9.2.7 Balloon Ratings 9.2.8 Principles of Balloon Inflation and Deflation 9.2.9 Choosing an Appropriate-Sized Balloon for a Procedure 9.2.10 Clinical Needs of a Balloon 9.2.11 Balloon Catheter Design 9.2.11.1 Rapid Exchange Design (Fig. 9.6) 9.2.11.2 Over-the-Wire Design (Fig. 9.7) 9.2.12 List of Applications of a Balloon Catheter 9.2.13 Complications 9.2.14 Occlusion Balloons 9.2.15 Angioplasty–Pearls 9.2.16 Advances in Balloon Technology 9.3 Stents 9.3.1 Basic Design (Fig. 9.8) 9.3.2 Types and Their Engineering 9.3.3 Stent Materials and Characteristics 9.3.4 Raw Material Form 9.3.5 Fabrication 9.3.6 Geometry 9.3.7 Additions 9.3.8 Drug-Eluting Stents 9.3.9 Mechanism of Expansion 9.3.10 Applications of Stents 9.3.10.1 Arterial Indications 9.3.10.2 Venous Indications 9.3.10.3 Non-vascular Indications 9.3.11 Uncovered vs. Covered (PTFE) SEMS 9.3.12 Stent Grafts 9.3.13 Complications Unique to Stent Placement References 10: Vascular Access 10.1 Introduction 10.2 Indications 10.3 Hardware 10.3.1 Intravenous Cannula 10.3.2 Puncture Needle 10.3.3 Arterial Access Sheath 10.4 Local Anesthesia 10.5 Peripherally Inserted Central Catheter and Central Venous Access Devices 10.6 General Considerations Before Procedure 10.7 Arterial Access 10.7.1 Gaining Access/Placement of Catheter: Seldinger Technique 10.7.2 Arterial Access Sites 10.7.2.1 Common Femoral Artery 10.7.2.2 High Brachial or Axillary Artery 10.7.2.3 Radial Artery 10.7.2.4 Pedal Access [3] 10.7.2.5 Others 10.8 Post-procedure Care 10.8.1 Manual Compression 10.8.2 Vascular Closure Devices (VCD) 10.9 Complications [5–8] 10.10 Venous Access 10.10.1 Common Femoral Vein 10.10.2 Internal Jugular Vein 10.10.3 Subclavian Vein Access 10.10.4 Upper Extremity Vein Access 10.11 Conclusion References Part II: Vascular Interventions 11: Neurointerventions Including Aneurysm Interventions 11.1 Introduction 11.2 Neurovascular Interventions 11.3 Endovascular Management of Intracranial Aneurysms 11.3.1 Introduction 11.3.2 Pathology and Clinical Aspects 11.3.3 Clinical Presentation 11.3.4 Imaging of Aneurysms 11.3.5 Management of Intracranial Aneurysms 11.3.6 Which Aneurysms to Treat? 11.3.7 Complete Morphological Evaluation of Aneurysms 11.3.8 Endovascular Techniques 11.3.9 General Technical Guidelines 11.3.10 Simple Coiling 11.3.11 Balloon-Assisted Coiling 11.3.12 Stent-Assisted Coiling 11.3.13 Flow Diverter/Braided Stents 11.3.14 Stent Graft 11.3.15 Parent Artery Occlusion 11.3.16 Endosaccular Devices 11.4 Management of Subarachnoid Hemorrhage 11.4.1 Pathophysiology 11.4.2 SAH-Evaluation and Immediate Management 11.4.3 Management of Complications 11.5 Follow-Up and Monitoring References 12: Endovascular Treatment of Acute Stroke 12.1 Introduction 12.2 Case Selection for Mechanical Thrombectomy 12.3 Technical Aspects of Mechanical Thrombectomy (Figs. 12.1, 12.2, 12.3 and 12.4) 12.4 Thrombectomy Techniques 12.5 Aspiration Technique 12.5.1 Stentriever Technique 12.6 Combination Technique 12.7 Balloon Guide Catheters (BGC) 12.8 Special Situations 12.8.1 Posterior Circulation Stroke 12.8.2 Tandem Occlusions 12.8.3 Intracranial Atherosclerotic Disease (ICAD) 12.8.4 Medium Vessel Occlusions (MeVO) 12.9 Complications 12.10 Immediate Post-procedure Care References 13: Interventions in Intracranial and Spinal Arteriovenous Malformations 13.1 Introduction 13.2 Brain AVMs 13.2.1 Introduction 13.2.2 Epidemiology 13.2.3 Pathology and Clinical Aspects 13.2.4 Classification 13.2.5 Angioarchitecture of AVM 13.2.6 Imaging in Cerebral AVMs 13.2.7 Grading of Cerebral AVMs 13.2.8 Treatment of Brain AVMs 13.2.8.1 Indications and Goals 13.2.8.2 Endovascular Treatment (Embolization) of Brain AVMs Role of EVT Advances in Endovascular Devices and Embolic Agents Embolic Agents Embolization Techniques Technical Aspects of Glue Embolization Embolization by Copolymers: Technical Aspects 13.3 Intracranial Dural Arterio-Venous Fistulas (DAVFs) 13.4 VGAM 13.4.1 Embryological and Morphological Considerations 13.4.2 Natural History and Clinical Presentations 13.4.3 Management (Fig. 13.19) 13.5 Spinal Vascular Malformations 13.5.1 Introduction 13.5.2 Anatomy 13.5.3 Classification and Clinical Features 13.5.4 Treatment of Spinal Vascular Malformations 13.5.4.1 SDAVF (Fig. 13.21) 13.5.4.2 SCAVS (Figs. 13.22 and 13.23) 13.5.4.3 Spinal Epidural AVMs 13.5.4.4 Metameric AVMs References 14: Other Neurointerventions 14.1 Introduction 14.2 Direct CCF 14.2.1 Relevant Anatomy and Pathogenesis 14.2.2 Treatment 14.3 Epistaxis 14.4 Neck Vessel Pathologies 14.4.1 Pediatric Pseudoaneurysms of the Neck 14.4.2 Etiopathogenesis 14.4.3 Clinical Presentation 14.4.4 Management 14.5 Intra-Arterial Chemotherapy for Retinoblastoma 14.6 Preoperative Embolization for Vascular Tumors References 15: Vascular Interventions in Head and Neck 15.1 Introduction 15.2 Vascular Malformations of the Head and Neck 15.3 Percutaneous Sclerotherapy of Head and Neck Low-Flow Vascular Malformations and Cystic Lesions 15.3.1 Sclerosing Agents and Procedure Technique 15.3.2 Treatment Response and Follow-Up 15.4 Endovascular Embolization of Head and Neck Tumours and Arteriovenous Malformations 15.4.1 Principles and Technique of Embolization 15.4.2 Embolization Agents 15.4.3 Embolization for Intractable Epistaxis 15.4.4 Principles and Technique of Embolization 15.5 Conclusion References 16: Carotid Artery Interventions 16.1 Introduction 16.2 Measurement of Carotid Artery Stenosis 16.2.1 Imaging 16.2.2 Management of Carotid Artery Stenosis 16.2.2.1 Symptomatic Carotid Artery Stenosis 16.2.2.2 Asymptomatic Carotid Artery Stenosis 16.2.3 Best Medical Therapy 16.3 Carotid Artery Stenting 16.3.1 Preprocedure 16.3.2 Hardware 16.3.2.1 Procedure 16.4 Types of Carotid Stents 16.5 Complications 16.5.1 Early Complications 16.5.2 Late Complications 16.6 Internal Carotid Artery Stenting 16.7 Conclusion References 17: Central Venous Access 17.1 Introduction 17.2 Indications for Central Venous Access 17.3 Types of Central Venous Catheters 17.3.1 Non-tunnelled Central Venous Catheters 17.3.2 Access Sites 17.3.3 Technique of Access 17.3.4 Approach to IJV Cannulation 17.3.5 Approach to SCV Cannulation 17.3.6 USG-Guided Approach 17.3.7 Vein Cannulation Technique 17.4 Complications of CVCs 17.5 Peripherally Inserted Central Catheter (PICC) 17.6 Tunnelled Catheters 17.6.1 Totally Implantable Catheters 17.7 Approach to Venous Access Catheter Selection in Adults References 18: Interventions of the Aorta 18.1 Introduction 18.2 Anatomical Considerations 18.3 Aortic Dissection 18.3.1 Introduction 18.3.2 Classification 18.3.2.1 Morphological/Anatomical Classification 18.3.2.2 Clinical Classification for TBAD 18.3.2.3 Natural History 18.3.2.4 Imaging Options 18.3.2.5 Indications for Treatment 18.3.2.6 Conventional Management Plan 18.3.2.7 Prerequisites for Endovascular Management (Table 18.1) 18.4 Aortic Aneurysms 18.4.1 Overview 18.4.2 Classification 18.4.3 Indication for Repair of Descending Thoracic Aortic Aneurysm (Tables 18.2 and 18.3) 18.4.4 Thoraco-Abdominal Aortic Aneurysm 18.4.4.1 Classification 18.4.4.2 Indications of Repair 18.4.4.3 Endovascular Repair Can Be Performed via Two Approaches 18.4.5 Abdominal Aortic Aneurysm (AAA) 18.4.5.1 Abdominal Aortic Aneurysm: Natural History 18.4.5.2 Indications for Management (ESVS 2024) 18.4.5.3 Endovascular Intervention 18.4.6 Intramural Hematoma and Penetrating Atherosclerotic Ulcers 18.4.6.1 Epidemiology 18.4.6.2 Classification 18.4.6.3 Pathophysiology 18.4.7 PAU 18.4.7.1 Imaging 18.4.7.2 Prognosis 18.4.7.3 Management 18.4.8 PAU 18.5 Procedure for Aortic Stent-Graft (Fig. 18.14) 18.5.1 Access Site 18.5.2 Procedure 18.5.3 Post-Procedure Care 18.5.4 Follow-Up Imaging 18.6 Complications of Endovascular Intervention 18.6.1 Device-Related Complications 18.6.2 Systemic Complications 18.7 Endoleaks 18.7.1 Imaging in Endoleak 18.7.2 Important Points Regarding Surveillance Image Interpretation (Figs. 18.15, 18.16 and 18.17) 18.7.3 Management of Endoleaks References 19: Vascular Thoracic Interventions 19.1 Introduction 19.2 Bronchial Artery Embolization (BAE) 19.2.1 Common Causes of Haemoptysis 19.2.1.1 Indications for BAE 19.2.1.2 Contraindications for BAE 19.2.1.3 Pre-Procedure Evaluation 19.2.2 Bronchoscopy 19.2.2.1 Technique 19.2.2.2 Post-Procedure Care 19.2.2.3 Complications 19.2.2.4 Tips and Tricks 19.3 Pulmonary Artery Pseudoaneurysm (PAPA)/Pulmonary AVM (PAVM) Embolization 19.3.1 Pre-Procedure Evaluation 19.3.1.1 Indications for PAVM Embolization [9] 19.3.1.2 Technique 19.3.2 Post-Procedure Care 19.3.3 Complications 19.3.4 Tips and Tricks 19.4 Interventions in Superior Vena Cava Syndrome 19.4.1 Pre-Procedure Evaluation 19.4.2 Technique 19.4.3 Complications 19.4.4 Post-Procedure Follow-Up 19.5 Thoracic Duct Interventions 19.5.1 Pre-Procedure Evaluation 19.5.2 Lymphangiography Technique 19.5.3 Thoracic Duct Embolization Technique 19.5.4 Complications 19.5.4.1 Complications Related to Lymphangiography 19.5.4.2 Central Lymphatic Access Complications 19.5.5 Contraindications to Thoracic Duct Embolization References 20: Interventions of the Pulmonary Arteries 20.1 Introduction 20.2 Pulmonary Embolism 20.2.1 Risk Stratification 20.2.2 Pre-Procedure Evaluation for Pulmonary Artery Interventions 20.2.3 Pulmonary Angiography 20.2.3.1 Technique 20.2.3.2 Post-Procedure Care 20.2.3.3 Complications 20.2.4 Treatment of High-Risk Pulmonary Embolism 20.2.4.1 Intravenous Thrombolysis 20.2.4.2 Catheter-Directed Thrombolysis 20.2.4.3 Mechanical Thrombectomy Devices that Fragment the Thrombus Without Removal Rheolytic Thrombectomy Devices Aspiration Thrombectomy Devices Shaped-Diagnostic Catheters and Percutaneous Transluminal Angioplasty Balloon Catheters 20.3 Pulmonary Arteriovenous Malformations 20.3.1 Clinical Manifestations [16, 17] 20.3.2 Types of PAVM [19] 20.3.3 Radiological Findings 20.3.4 Endovascular Management 20.3.4.1 Pre-Procedure Evaluation 20.3.4.2 Technique 20.3.4.3 Post-Procedure Care 20.3.4.4 Complications and Their Management 20.3.4.5 Current Evidence 20.4 Pulmonary Artery Aneurysm 20.4.1 Endovascular Management 20.4.1.1 Technique References 21: Hepatic Arterial Interventions 21.1 Introduction 21.2 Hepatic Arterial Anatomy 21.2.1 Normal Celiac Anatomy 21.2.2 Normal Hepatic Artery Anatomy 21.2.3 Variant Anatomies 21.2.4 Extrahepatic Supply of HCC 21.3 Hepatic Arterial Interventions for Hepatocellular Carcinoma (HCC) 21.3.1 Transarterial Chemoembolization (TACE) 21.3.1.1 Indications: (See Table 21.2) 21.3.1.2 Contraindications 21.3.1.3 Patient Selection 21.3.1.4 Patient Preparation 21.3.1.5 Principle and Procedure 21.3.1.6 Response Evaluation 21.3.1.7 TACE Failure 21.3.1.8 TACE Discontinuation 21.3.1.9 Complications 21.3.2 Transarterial Radioembolization (TARE) 21.3.2.1 Indications: (See Table 21.2) 21.3.2.2 Contraindications [24] 21.3.2.3 Agents Used 21.3.2.4 First Visit (Planning) 21.3.2.5 Second Visit (Microsphere Injection) 21.3.2.6 Complications 21.3.3 Transarterial Bland Embolization (TAE) 21.3.4 Hepatic Artery Infusion Chemotherapy (HAIC) 21.4 Hepatic Arterial Interventions in Non-HCC Liver Tumors 21.4.1 Neuroendocrine Liver Metastasis (NELM) 21.4.2 Other Liver Metastases 21.4.3 Intrahepatic Cholangiocarcinoma (IHCC) 21.4.4 Benign Liver Tumors 21.4.4.1 Hemangiomas 21.4.4.2 Focal Nodular Hyperplasia 21.4.4.3 Hepatocellular Adenoma 21.4.4.4 Polycystic Liver Disease 21.5 Hepatic Arterial Interventions in Post-Transplant Patients 21.6 Interventions in Hepatic Artery Aneurysms and Pseudoaneurysms 21.7 Interventions in Arterioportal Fistulas 21.8 Hepatic Parenchyma Repopulation References 22: Interventions of the Hepatic Veins, Inferior Vena Cava, and Portal Vein 22.1 Introduction 22.2 Transjugular Liver Biopsy (TJLB) 22.2.1 Patient Preparation 22.2.2 Procedure 22.2.3 Post-Procedural Care 22.2.4 Complications 22.3 Transjugular Intrahepatic Portosystemic Shunt (TIPS) 22.3.1 Indications of TIPS [10, 11] 22.3.2 Contraindications of TIPS [12–14] 22.3.3 Pre-Procedural Evaluation [12–14] 22.3.4 Technique 22.3.5 Post-Procedural Care 22.3.6 Complications of TIPS 22.3.6.1 Extrahepatic Portal Vein Puncture [18, 19] 22.3.6.2 Hepatic Artery Injury [18–20] 22.3.6.3 Post-TIPS Hepatic Encephalopathy [21, 22] 22.3.6.4 Post-TIPS Hepatic Failure (PTLF) [18, 21–23] 22.3.6.5 TIPS Dysfunction Resulting in Recurrent Symptoms of Portal Hypertension [18, 19, 21] 22.3.7 Discussion 22.4 Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) 22.4.1 Indications and Contraindications of BRTO 22.4.2 Pre-Procedural Evaluation 22.4.3 Requirements 22.4.4 Sclerosants 22.4.5 Relevant Anatomy 22.4.6 Techniques 22.4.7 Complications of Shunt Occlusion Procedures [39, 42, 43] 22.4.8 Discussion 22.5 Portal Vein Thrombosis (PVT) 22.5.1 Cirrhosis with PVT 22.5.2 Non-cirrhotics with PVT 22.6 HV and IVC Angioplasty 22.6.1 Techniques of HV/IVC Angioplasty 22.6.2 HV/IVC Stenting 22.6.3 Tips/Dips 22.6.4 HV/IVC Thrombolysis 22.6.5 Discussion 22.7 Portal Vein Embolization 22.7.1 Mechanism of Liver Regeneration 22.7.2 Portal Vein Anatomy and Its Variants 22.7.3 Concept of Standardized FLR (sFLR) 22.7.4 Indications and Contraindications 22.7.5 Pre-Procedural Evaluation 22.7.6 Techniques 22.7.7 Embolizing Materials 22.7.8 Hypertrophy Response 22.7.9 Complications of PVE 22.7.10 Modification of PVE 22.7.10.1 Sequential TAE and PVE [76, 84] 22.7.10.2 PVE and Two-Staged Hepatectomy [85, 88] 22.7.10.3 Simultaneous PVE and HVE (Total Liver Deprivation) [89, 90] 22.7.11 Discussion 22.8 Transjugular Kidney Biopsy (TJKB) 22.8.1 Indications 22.8.2 Rationale 22.8.3 Pre-Procedural Workup 22.8.4 Techniques 22.8.5 Diagnostic Yield and Complication 22.9 IVC Filter 22.9.1 Types of IVC Filter 22.9.2 Patient Preparation 22.9.3 Normal Location of Filter (Figs. 22.12 and 22.13) 22.9.4 Procedure 22.9.5 Complications [98, 102] References 23: Interventions of Renal Vessels 23.1 Introduction 23.2 Anatomy 23.2.1 Arterial Anatomy 23.2.2 Venous Anatomy 23.3 Arterial Interventions 23.3.1 Renovascular Hypertension 23.3.2 Atherosclerotic Renal Artery Stenosis 23.3.3 Non-atherosclerotic RAS 23.3.4 Takayasu Arteritis (TA) 23.3.5 Fibromuscular Dysplasia (FMD) 23.4 Imaging in RAS 23.5 Revascularization in RAS 23.5.1 Indications and Guidelines for Endovascular Revascularization in RAS 23.5.2 Percutaneous Transluminal Angioplasty (PTRA) and Stenting 23.5.2.1 Preprocedural Evaluation 23.5.2.2 Preprocedural Instructions 23.5.2.3 Procedure 23.5.2.4 Angiography 23.5.2.5 Balloon Angioplasty 23.5.2.6 Cutting Balloon Angioplasty 23.5.2.7 Stenting 23.5.2.8 Embolic Protection Device’s (EPD) Role in PTRA and Stenting 23.5.2.9 Post-Procedural Care 23.5.2.10 Complications 23.6 Renal Denervation in Resistant Hypertension 23.6.1 Procedure 23.7 Renal Artery Aneurysms (RAAs) 23.7.1 Definitive Treatment 23.7.2 Endovascular Management in RAAs 23.8 Renal Arteriovenous Shunts (Malformations and Fistulas) 23.8.1 Etiology 23.8.2 Clinical Presentation 23.8.3 Endovascular Management 23.9 Endovascular Intervention for Renal Neoplasms 23.9.1 Angiomyolipoma 23.9.2 Renal Cell Carcinoma (RCC) 23.10 Venous Interventions 23.10.1 Nutcracker Syndrome (NCS) 23.10.1.1 Diagnosis 23.10.1.2 Management 23.10.1.3 Endovascular Management 23.10.1.4 Procedure 23.10.1.5 Complications 23.10.2 Renal Vein Thrombosis 23.10.2.1 Clinical Presentation 23.10.2.2 Management 23.10.2.3 Role of Catheter-Directed Thrombectomy (CDT) and Thrombolysis 23.10.2.4 Procedure References 24: Interventions of the Mesenteric Arterial Circulation 24.1 Introduction 24.2 Relevant Anatomy 24.3 Mesenteric Ischemia 24.3.1 Clinical Features 24.3.2 Imaging 24.3.3 Treatment 24.3.3.1 Techniques of Endovascular Interventions 24.3.3.2 Intra-Arterial Thrombolysis 24.3.3.3 Mechanical Thrombectomy 24.3.3.4 Balloon Angioplasty and Stenting 24.4 Gastrointestinal Hemorrhage 24.4.1 Clinical Features 24.4.2 Endoscopy 24.4.3 Imaging 24.4.4 Technique of Endovascular Embolization (Figs. 24.2, 24.3, and 24.4) 24.4.4.1 Principles of Embolization 24.4.4.2 Complications 24.5 Bariatric Embolization 24.5.1 Technique References 25: Interventions of the Pelvic Vessels 25.1 Introduction 25.2 Uterine Artery Embolization (UAE) 25.2.1 Indications [1, 2] 25.2.2 Contraindications [1, 2] 25.2.3 Relevant Vascular Anatomy [2] 25.2.4 Preprocedural Evaluation 25.2.5 Technique 25.2.6 Post-Procedural Care 25.2.7 Complications 25.2.8 Outcome 25.3 Prostatic Artery Embolization (PAE) 25.3.1 Rationale Behind PAE 25.3.2 Indications [17, 18] 25.3.3 Contraindications [18] 25.3.4 Preprocedural Evaluation [17] 25.3.5 Clinical Assessment 25.3.6 Urodynamic Testing, and Post-Void Residual (PVR) Urine 25.3.7 Imaging 25.3.7.1 Ultrasonography (USG) 25.3.7.2 Computed Tomography (CT) 25.3.7.3 Magnetic Resonance Imaging (MRI) 25.3.8 Requirements for Prostatic Artery Embolization [17, 18] 25.3.9 Relevant Vascular Anatomy 25.3.10 Technique 25.3.11 Complications 25.3.12 Post-Procedural Follow-Up 25.3.13 Outcome 25.4 Varicocele Embolization 25.4.1 Indications [22, 26] 25.4.2 Advantages of Percutaneous Embolization Over Surgery [25, 26] 25.4.3 Contraindications (Relative) to Percutaneous Varicocele Embolization 25.4.4 Relevant Vascular Anatomy 25.4.5 Preprocedural Evaluation [23, 25] 25.4.6 Technique 25.4.6.1 Anesthesia and Radiation [25] 25.4.6.2 Venous Access [25, 27, 28] 25.4.6.3 Venography [25, 27] 25.4.6.4 Embolization [25, 27, 29–31] 25.4.7 Post-Procedural Care 25.4.8 Complications 25.4.9 Outcome 25.5 Pelvic Congestion Syndrome 25.5.1 Indication [38] 25.5.2 Contraindications [38] 25.5.3 Preprocedural Evaluation 25.5.4 Relevant Vascular Anatomy 25.5.5 Technique 25.5.6 Post-Procedural Care 25.5.7 Complications 25.5.8 Outcome 25.6 Penile Angiography 25.6.1 Penile Vascular Anatomy 25.6.2 Technique 25.6.3 Complications 25.6.4 Outcome References 26: Interventions of the Extremity Arteries 26.1 Relevant Anatomy of Lower Limb Arteries 26.2 Peripheral Arterial Disease (PAD) 26.2.1 Introduction 26.2.2 Classification Systems 26.2.2.1 Clinical Classification 26.2.2.2 Fontaine Classification 26.2.3 Rutherford Classification for Chronic Limb Ischemia 26.2.4 Anatomical Classification 26.2.5 Diagnostic and Imaging Modalities 26.2.5.1 Non-imaging/Functional Modalities 26.2.5.2 Imaging Evaluation 26.2.6 Management Strategies 26.2.6.1 Optimal Medical Therapy, Risk Factor Modification, and Supervised Exercise Program 26.2.6.2 Indications of Revascularization 26.2.6.3 Revascularization Strategies 26.3 Endovascular Revascularization: Angioplasty and Stenting 26.3.1 Evidence-Based Guidelines for Peripheral Arterial Interventions 26.3.2 Preprocedural Evaluation 26.3.3 Technique of Angioplasty in Peripheral Arterial Disease 26.3.4 End Points of Angioplasty 26.3.5 Complications 26.3.6 Stenting 26.3.7 Post-Procedure 26.4 Technical and Clinical Outcomes 26.5 Recent Advances 26.5.1 Advances in Angioplasty Balloons 26.5.2 Drug-Eluting Technology 26.5.3 Bioresorbable Stents 26.5.4 Techniques for Chronic Total Occlusion (CTO) 26.5.5 Advances in Debulking and Plaque Removal 26.5.6 Pedal Arch Revascularization 26.5.7 Percutaneous Deep Vein Arterialization (DVA) 26.5.8 Therapeutic Angiogenesis and Stem Cell Therapy 26.6 Acute Limb Ischemia 26.7 Popliteal Artery Entrapment Syndrome (PAES) 26.8 Genicular Artery Embolization (GAE) References 27: Interventions of the Extremity Veins 27.1 Introduction 27.2 Relevant Anatomy 27.3 Varicose Veins 27.3.1 Clinical Evaluation 27.3.2 Physical Examination 27.3.3 Sonological Evaluation 27.3.3.1 Duplex Sonographical Evaluation 27.3.4 Current Consensus among Different Vascular Societies 27.3.5 Endovascular Interventions for Varicose Veins 27.3.5.1 Thermal Ablation Endovenous Laser Ablation Radiofrequency Ablation Endovenous Steam Ablation 27.3.5.2 Non-thermal Ablative Methods Foam Sclerotherapy Cyanoacrylate Closure (CAC) Mechanochemical Ablation (MOCA) Cryosclerosis 27.4 Deep Vein Thrombosis 27.4.1 Diagnosis 27.4.1.1 Pre-Test Probability 27.4.1.2 D-Dimer Assessment 27.4.1.3 Radiological Evaluation 27.4.2 Indications for Intervention 27.4.3 Thromboreductive Therapies—Rationale 27.4.4 Patient Selection—Anatomic and Clinical Considerations 27.4.5 Endovascular Interventions for DVT 27.4.5.1 Catheter-Directed Thrombolysis 27.4.5.2 Pharmacomechanical Catheter-Directed Thrombolysis (PCDT) First-Generation Pharmacomechanical Catheter-Directed Thrombolysis Single-Session (Second-Generation) Pharmacomechanical Catheter-Directed Thrombolysis 27.4.5.3 Endpoint Assessment for Endovascular Thrombolysis 27.5 Endovascular Therapy for Acute Pulmonary Embolism 27.5.1 Pulmonary Embolism (PE) 27.5.2 Clinical Features 27.5.3 Imaging Evaluation 27.5.4 Management 27.5.5 Endovascular Techniques References 28: Endovascular Interventions in Hemodialysis Access Fistulas 28.1 Introduction 28.2 Anatomy of AV Fistula 28.3 Clinical Presentation of Dysfunctional Fistula 28.3.1 Stages of the Fistula 28.3.2 Imaging Evaluation 28.3.3 Pre-procedure and Intraprocedural Care 28.4 Endovascular Management 28.4.1 Nonmature Fistulas 28.4.2 Anastomotic and Juxta-Anastomotic Venous Stenosis 28.4.3 Acute Thrombosis 28.5 Central Venous Stenosis 28.6 Distal Hypoperfusion Ischemic Syndrome (DHIS) 28.7 Pseudoaneurysm References 29: IR Management of Vascular Malformations 29.1 Introduction 29.2 Low-Flow Vascular Malformations 29.2.1 Sclerotherapy for Low-Flow Vascular Malformations 29.2.1.1 Pre-procedural Requirements 29.2.1.2 Procedure 29.2.1.3 Post-procedure Care 29.2.1.4 Choice of Sclerosant Agent (Table 29.2) Ethanol Detergent Sclerosant Bleomycin Doxycycline OK-432 (Picibanil) 29.2.1.5 Complications 29.3 High-Flow Vascular Malformations 29.3.1 Endovascular Therapy for High-Flow Vascular Malformations 29.3.1.1 Pre-procedure Evaluation 29.3.1.2 Technique 29.3.1.3 Complications 29.4 Fibro-Adipose Vascular Anomaly (FAVA) 29.5 Conclusion References 30: Vascular Interventions in Trauma 30.1 Introduction 30.2 Splenic Injuries 30.2.1 Indications of SAE 30.2.2 Technique 30.2.3 Patient Preparation 30.2.4 Procedure 30.2.5 Embolizing Agent 30.2.6 Post-procedural Care 30.2.7 Complication 30.3 Hepatic Injury 30.3.1 Background 30.3.2 Indication 30.3.3 Technique 30.3.4 Patient Preparation 30.3.5 Procedure (Figs. 30.3 and 30.4) 30.3.6 Embolization Agent 30.3.7 Post-procedural Care 30.3.8 Complications 30.4 Peripheral Vascular Injuries (PVI) 30.4.1 Background 30.4.2 Indication 30.4.3 Patient Preparation 30.4.4 Procedure (Figs. 30.5 and 30.6) 30.4.5 Embolization Agent 30.4.6 Post-procedural Care 30.4.7 Complications 30.5 Pelvic Trauma 30.5.1 Background 30.5.2 Indication 30.5.3 Technique 30.5.4 Patient Preparation 30.5.5 Proced