Interventional radiology. Definition of interventional radiology. Reconstructive heart surgery
Interventional radiology- a branch of medical radiology that develops the scientific foundations and clinical
the use of therapeutic and diagnostic manipulations carried out under the control of radiation research.
Interventions consist of two stages. The first stage includes a radiological examination (X-ray television
transillumination, computed tomography, ultrasound or radionuclide scanning, etc.), aimed at establishing
the nature and extent of the injury. At the second stage, usually without interrupting the study, the doctor performs the necessary medical
manipulations (catheterization, puncture, prosthetics, etc.), which are often not inferior in efficiency, and sometimes even superior
surgical interventions, and at the same time possessing a number of advantages in comparison with them. They are more
sparing, in most cases do not require general anesthesia; duration and cost of treatment
decrease; morbidity and mortality are reduced. Interventions can be the first step
preparation of sharply weakened patients for the operation necessary in the subsequent operation.
Indications for interventional interventions are very wide, which is associated with a variety of tasks that can be solved with
using interventional radiology techniques. General contraindications are the serious condition of the patient, acute
infectious diseases, mental disorders, function decompensation of cardio-vascular system, liver, kidneys,
use of iodine-containing radiopaque substances- Hypersensitivity to iodine preparations.
Preparation of the patient begins with explaining to him the purpose and methodology of the procedure. Depending on the type of intervention
use different forms premedication and anesthesia. All interventional interventions can be conditionally divided into two
groups: X-ray endovascular and extravasal.
The radioendovascular interventions that have received the most recognition are intravascular
diagnostic and therapeutic manipulations carried out under x-ray control. Their main types are
X-ray endovascular dilatation, or angioplasty, X-ray endovascular prosthetics and X-ray endovascular
occlusion.
Extravasal interventions include endobronchial, endobiliary, endoesophageal,
endourinal and other manipulations.
X-ray endobronchial interventions include catheterization bronchial tree carried out under control
X-ray television transillumination, in order to obtain material for morphological studies from inaccessible to
bronchoscope sites. With progressive strictures of the trachea, with softening of the cartilage of the trachea and bronchi,
endoprosthesis using temporary and permanent metal and nitinol prostheses that do not change their
positions that do not have a secondary effect on the tracheal wall, which provides further therapeutic effect With
high quality of life.
Endobiliary X-ray surgical interventions are being improved. With obstructive jaundice through
percutaneous puncture and catheterization of the bile ducts perform their decompression and create an outflow of bile - external or
internal drainage of the biliary tract. AT bile ducts drugs are administered to dissolve small calculi, with the help of
special tools remove small stones from the ducts, expand biliodigestive anastomoses, in particular anastomoses
between common bile duct duodenum when it is narrowed. In severely debilitated patients with acute
cholecystitis, transcatheter obliteration is performed cystic duct followed by anti-inflammatory therapy
culminating in crushing and removal of stones. Increasing use is being made of percutaneous gastrostomy,
jejunostomy, cholecystostomy. To eliminate narrowing of the digestive canal, incl. esophagus, perform balloon dilatation.
The basis of X-ray endourinal manipulations is most often percutaneous puncture and catheterization of the renal pelvis with
obstruction of the ureter. In this way, manometry and contrast are performed. pelvicalyceal system(antegrade
pyelography), enter medicinal substances. Through an artificially created nephrostomy, a biopsy is performed, dissection
stricture of the ureter and its balloon expansion. Noteworthy is dilatation and endoprosthetics of the urethra in case of adenoma.
prostate and similar manipulations for cervical stricture.
Endourological interventions are interventional therapeutic and diagnostic manipulations performed under x-rays.
Television and / or endoscopic control, produced from percutaneous (percutaneous) or transurethral (through
urethra) accesses.
Transurethral catheterization and stenting of the kidney are used for retrograde resolution of obstruction of the upper
urinary tract, with prolonged standing of the ureteral stone in place or for its displacement for DLT in the pelvis (increases
efficiency of DLT). A separate indication for the installation of an internal stent are large, multiple and staghorn
stones in a normally functioning kidney, which can be subjected to ESWL against the background of internal drainage.
A ureteral stent is a specially designed tube made from a flexible plastic material that is placed
into the ureter, allowing the so-called closed drainage of the urinary tract.
The length of the stent varies from 24 to 30 cm. Stents are designed specifically for placement in urinary system. Upper and
the lower parts of the stent have roundings - curls that do not allow it to move. The stent is usually placed under general anesthesia.
using a special instrument - a cystoscope or ureteroscope, which is passed into the bladder through the urethra -
urethra.
The stent is in place until the obstruction is relieved. It depends on the cause of the obstruction and the nature of its treatment.
Most patients require a stent for a short period of time, from a few weeks to a few months.
However, a stent, if properly positioned, can stay in the body for up to 3 months without replacement. When the main problem is
not kidney stone, the stent can stay in the body even longer. There are special stents that can be placed
inside for a very long time.
How to remove a stent is a short procedure and consists of removing the stent using a cystoscope.
Ureteral stents are designed to enable patients to lead a normal life. However, wearing stents can
accompanied by side effects, most of them are not dangerous to health.
Most frequent side effects:
* More frequent than usual urge to urinate.
* admixture of blood in the urine.
* feeling incomplete emptying Bladder.
* Pain in the kidney area when urinating.
It is necessary to monitor the stent (ultrasound, survey urography), because after 1.5-2 months. the stent may begin to cover
salt crystals, which can lead to increased pain, hematuria.
Interventional methods for examining the fetus and treating its diseases are coming into practice. Yes, under control.
ultrasound scanning, early amniocentesis, biopsy of the chorion, fetal skin, blood sampling, elimination of obstruction
urinary tract.
Interventional studies are used for puncture of non-palpable formations in the mammary gland, identified with
using mammography. The puncture is performed under the control of X-ray television transillumination. After research in tissue
glands leave a special needle, which serves as a guide for sectoral resection. under fluoroscopy or
computed tomography, percutaneous transthoracic punctures of intrapulmonary and mediastinal formations are performed.
Similarly, incl. under the control of ultrasound scanning, puncture and biopsy of pathological foci in
other tissues and organs. The most common interventional manipulations were puncture of cysts and abscesses of various
localization with their subsequent drainage. The technique is used for cysts of the thyroid, pancreas, kidneys, liver
etc., abscesses of the lungs, liver, pancreas, abdominal cavity. Abscess is punctured with a stylet catheter under control
ultrasound scan, computed tomography or fluoroscopy. After removal of purulent contents through the catheter
drugs are injected into the cavity. The catheter is left in the cavity to repeat the procedure. By using beam methods
studies observe the dynamics of the process.
The role of interventional radiology in diseases of the musculoskeletal system is significant. under the control of radiation
methods, biopsy of the synovial membranes, trepanobiopsy, interventional interventions on intervertebral discs, in
including percutaneous lumbar decompression and discectomy, as well as chemonucleosis (introduction into the nucleus pulposus of the disc
proteolytic enzymes with subsequent removal of cartilage hernia fragments), etc.
To the most common organ interventions gastrointestinal tract, can be attributed: percutaneous
gastroenterostomy; balloon dilatation and stenting of the esophagus and intestines; drainage of intraperitoneal and
retroperitoneal abscesses.
Although not yet clinical research, but experimental studies in the field of new polymer technologies
promising. Doctors from Germany (T. Schmitz Rode et al.) have developed non-contact controlled micro- and
nanocarriers as a new therapeutic approach. The essence of this technique is to encapsulate a special
substance that has magnetic properties(magnetite) in heat-sensitive nano- and microparticles of polyacrylamide. it
makes it possible to inductively heat these particles to temperatures above body temperature (greater than 40°C) by
using an external high-frequency magnetic field (magnetic induction spiral).
An increase in temperature leads to certain changes inside the matrix of the thermosensitive polymer, which is accompanied by
Questions
1. Introduction.
2. Definition of interventional radiology.
3. Vascular interventions.
4. Angiography.
5. Arterial angioplasty.
6. The fight against pathological thrombosis.
7. Vascular embolizations.
9. Removal foreign bodies.
10. Non-vascular interventions.
11. Conclusion.
Didactic material, slide show:
1. Angiography room.
2. Instrumentation for angiography.
3. Scheme of percutaneous vascular catheterization according to Seldinger.
4. Causes of vascular obstruction.
5. Atherosclerotic occlusion and acute thrombosis of the left common iliac artery.
6. Nonspecific aortoaortitis - stenosis of the intrarenal aorta, right renal artery.
7. Obliterating endarteritis of vessels of the lower extremity.
8. Saccular aortic aneurysm.
9. Traumatic arteriovenous fistula.
10. Scheme of drainage of the liver with a self-fixing catheter
11. Drainage of a liver cyst under CT control.
12. Scheme of drainage of intrahepatic ducts.
13. Percutaneous drainage of the right hepatic duct.
Introduction
The 1970s and 1980s were marked by rapid progress in radiology. At this time, new diagnostic tools and methods were introduced and developed: computed tomography, ultrasound examinations, magnetic resonance imaging, digitalization of images. A very important point was also the formation of a new subdiscipline - interventional radiology (minimal invasive therapy, X-ray surgery). The greatest contribution to the development of this new direction was made by the American scientists Amplatz, Dotter, Gianturco, Rusch, Zeitler and the Swiss doctor Gruntzig. To date, there are many interventional techniques, a huge number of special tools that allow the treatment of a variety of vascular and non-vascular diseases. vascular pathology.
Definition of Interventional Radiology
Interventional radiology is a sub-discipline of radiology that includes treatments various diseases by using percutaneous accesses, catheters and other low-traumatic instruments, without anesthesia, under the control of radiation imaging methods. For procedures, there is a limited range of contraindications, they are characterized by safety, low cost, ease of implementation. All interventions can be conditionally divided into two categories - vascular and non-vascular interventions.
Vascular interventions
Vascular interventions consist of the following steps:
1. Angiographic study.
2. Change of catheters for a specific type of intervention.
3. Selective catheterization of the vessel on which the intervention is performed.
4. Angiographic control over the correct position of the catheter.
5. Intervention.
6. Angiographic control over the quality of the intervention.
7. Maintaining the post-intervention period.
Angiography
Angiographic examinations are carried out using angiographic devices equipped with a multifaceted scanning system, an image intensifier tube and automatic syringe injectors. Such systems are subject to strict requirements for dose loads, taking into account the duration of the procedure.
The study is carried out in a specially equipped room by an angiologist, his assistant, and an operating nurse.
The operating nurse prepares the instruments and preparations:
1. Special Seldinger needles. It is convenient to puncture only one wall of the artery with such a needle.
2. Specially modeled probes, depending on the nature and purpose of the study and manipulation.
3. Conductors in the form of a steel string, of various lengths.
4. Adapter with a three-way stopcock and cannula to it.
5. Syringes with needles.
6. Solutions (0.5% and 0.25% novocaine, 500 ml of saline with 1 ml (5000 IU) of heparin, contrast agents).
Mostly non-ionic contrast agents (omnipack, ultravist) are used in the amount of 6-60 ml. In order to avoid complications, it is recommended not to exceed the amount of injected contrast agent more than 1.5 ml/kg of the patient's weight.
Diagnostic angiography is performed for:
1. Determination of variants of vascular architectonics, obtaining an idea of the arterial, capillary and venous phases of angiography.
2. Definitions of the nature, topics and degree of vascular obstruction.
3. Identification of the source of bleeding.
4. Clarification of the localization of the pathological focus and its size.
5. In order to choose an embolizing agent for occlusion.
Contraindications to angiographic examination:
1. The general serious condition of the patient.
2. The presence of a history of allergic diseases.
3. Severe cardiovascular, respiratory and hepatic-renal insufficiency.
4. Significant violation of the blood coagulation system.
5. Hypersensitivity to iodine.
The last contraindication is relative. These patients are given injections of antihistamines for 3 days before the study.
Angiographic studies in adults and children over 12 years of age are performed under local anesthesia, in children younger age anesthesia is applied.
Most of research is carried out according to the Seldinger method, which consists of several stages:
1. Puncture of an artery with a Seldinger needle.
2. Introduction of the conductor into the artery.
3. Installation of a catheter in an artery.
In January 1964, Dotter decided to put his concept of intraluminal vessel remodeling into practice by dilating the vessel. An 82-year-old patient with obliterating atherosclerosis, who was threatened with amputation of her leg due to incipient gangrene, he dilates the stenosis of the artery using a system of coaxial, one after the other, bougie catheters. The results of the intervention were more than convincing. The patient manages not only to save his leg, but also to regain the ability to walk without experiencing pain 7,8 . Dotter called his method Percutaneous Intraluminal Angioplasty.
Charles Dotter believed that someday "catheters will replace the scalpel." In many ways, thanks to the ingenuity, perseverance and enthusiasm of C. Dotter, interventional medicine (interventional radiology) has taken the "first steps" towards its development as an independent field of medicine. Overcoming skepticism and misunderstanding of colleagues, Dotter, however, continued to implement more and more new ideas, many of which were subsequently "adopted". Many of them were years ahead of their time. Guidewires with safety J-tip, a floating balloon catheter, a 2-lumen balloon catheter, a vascular retriever and the first vascular stent this is not a complete list of tools created by Dotter.
The person who helped Dotter realize most of his ideas was William Cook, who founded the eponymous company for the production of instruments for interventional radiology. From Dotter's sketch of two telescopic catheters, Bill Cook produced the first "Dotter Dilation Set" in 1963 5 . The personal friendship between Dotter and Cook became the basis for a long and fruitful collaboration, thanks to which the experimental instruments of Dotter and other pioneering physicians, for a short time turned into serial samples. Starting by making catheters and guide wires in the kitchen of his own home, Cook has combined cutting-edge ideas and technology to create not just a manufacturing facility, but also a material base for further development and dissemination of intervention methods.
Dotter's ideas have spurred physicians around the world to further experiment and develop new techniques and tools. Some time later, another eminent innovator, Cesare Gianturco, sent Dotter a report of his successful dilatation of a femoral artery stenosis using a special balloon-ended catheter 9,10 . Dotter appreciated the ingenuity of his colleague, but the technical implementation of the idea seemed to him too imperfect at that time. The fact is that when inflated, such a balloon was severely deformed, and when it came into contact with a rigid atherosclerotic plaque, it over-inflated, taking the form hourglass and threatening to break the part of the vessel adjacent to the plaque. It will be nearly 10 more years before balloon dilatation is safe and effective enough to gain acceptance.
Unlike America, in Europe the ideas of the dotter were received with great interest and understanding. The technique of "dottering", as European doctors called it, took possession of the minds of the most progressive-minded scientists. Eberhard Zeitler in Nuremberg became a follower and popularizer of Dotter's ideas in Europe. In the early 1970s, Zeitler and later Werner Porstman continued to improve the balloon catheter, with several successful peripheral balloon angioplasties 2,4 .
At that time, a young doctor, Andreas Gruntzig, was doing an internship at the Zeitler clinic. Fascinated by the ideas of Dotter and Zeitler, he begins to look for ways to further improve the balloon catheter. Continuing his work at the University Hospital in Zurich, Switzerland, Grünzig, together with Professor of Technical University Hopf, is trying to find the right material to create a balloon that, when inflated, would take the form of a cylinder. Experimenting with various materials, he opts for polyvinyl chloride. Using self-made balloons, Grunzig performs several successful angioplasties, after which he manages to interest companies producing angiography instruments with his invention. COOK in the USA and Schnider in Switzerland start serial production of Grünzig balloon catheters. The method proposed by Grünzig is called Percutaneous Transluminal Balloon Angioplasty 2,4,9,10 .
Over the following years and throughout the entire period of the 1980s, the technique of percutaneous intraluminal angioplasty spread throughout the world. At the same time, the instruments used are being improved from year to year, the development companies continuously offer more and more advanced catheters and devices. Angioplasty is becoming an integral part of cardiology and vascular surgery. Cardiologists and radiologists have at their disposal a method that allows them to obtain comparable surgical operation results, but with less harm to the patient.
Development cardiovascular surgery since the late 50s, made possible appearance variety of endovascular interventions. Surgeons could not do without the participation of radiologists and invasive research methods, while radiologists increasingly tried to do without the help of surgeons. In the following decades, endovascular surgery has achieved tremendous success in the treatment of vascular pathology, congenital and acquired heart defects. Cardiovascular Interventional Radiology still rightfully remains priority industries.
Thanks to the talent and ingenuity of the scientists who stood at the origins of interventional medicine, interventional radiology has evolved from an applied diagnostic specialty into an independent branch of medicine, offering its own unique minimally invasive methods of treatment.
The success of radiologists in cardiovascular surgery has encouraged other physicians to use the same approaches in their own specialties. At present, the methods of interventional radiology have found application in almost all areas of medicine where, one way or another, the methods of radiation imaging are used: urology, surgery of the liver and gastrointestinal tract, neurosurgery, oncology, gynecology. Interestingly, the set of methods used in interventional radiology is almost universal and can be used in any field of medicine. Radiologists can "open" the occlusion of the vessel or, conversely, embolize the vessel or install a filter in its lumen, close the unnatural communication between vessels or organs, and, on the contrary, create it with therapeutic purpose, expand the constriction of a vessel or hollow organ with a balloon, and then maintain its patency with a scaffold stent.
As the methods invasive diagnostics began to be used in other areas of medicine, interventional radiologists were able to offer a solution to a number of complex problems facing several clinical disciplines at the same time. Here are just the most important of them: life-threatening bleeding in portal hypertension and trauma, drainage of the lumen hollow organs, restoration of the lumen tubular organs by stent placement, intravascular treatment various tumors, prevention and treatment of pulmonary embolism. In some cases, radiologists can offer alternative interventions to open surgery, in others, they can significantly simplify the subsequent work of surgeons, alleviating the patient's condition and minimizing the severity and risk of the operation.
In our country, doctors and scientists who worked in various fields medicine. In 1918, M.I. Pimenov created a special X-ray angiography laboratory at the Leningrad State X-ray, Radiological and Cancer Institute. The first human angiography was performed by S.A. Reinberg in 1924. Later, in 1930, a contrast study of the vessels of the extremities was applied by V.V. Krestovsky. Enthusiasts contrast studies became such famous surgeons as A.N. Bakulev, B.V. Petrovsky, E.N. Meshalkin, V.S. Savelyev, F.G. .Soloviev, N.N.Malinovsky, G.A.Natsvlishvili, N.I.Krakovsky, N.A.Lopatkin, Yu.A.Pytel 11 .
Schools of radiologists-radiologists involved, among other things, in the development and implementation of minimally invasive interventions, were created at the departments of the largest scientific institutes. At the origins of their creation were such eminent doctors as: P.N. Mazaev, M.A. Ivanitskaya, Yu.S. Petrosyan, L.S. Zingerman, I.Kh. Rabkin, L. D. Lindenbraten, I. L. Tager, G. A. Zedgenidze, A.F.Tsyb, L.S.Rozenshtraukh, K.B.Tikhonov, Yu.K.Neklasov, S.Ya.Marmorshtein, G.A.Kuchinsky, Yu.D.Volynsky, V.I.Prokubovsky and many others eleven .
At present, in many major scientific and treatment centers, departments of X-ray surgery and X-ray endovascular diagnostic and treatment methods have been established and are operating in large multidisciplinary hospitals throughout the country. Some centers have their own unique experience and international prestige. However, the issue of singling out interventional radiology as an independent field remains unresolved. medical specialty. In addition, the number of centers where doctors and residents could be properly trained in the methods of interventional radiology is negligible. Until recently, there was no specialized publication devoted to the problems of interventional radiology. Created for last years associations of interventional radiologists and the symposiums and seminars organized by them, of course, help to improve the skills of specialists and strengthen the authority of interventional radiology among doctors and health leaders. I would like to think that the possibilities and prospects of interventional radiology, which have not yet been fully disclosed in our country, will serve as an incentive that can push enthusiasts to decide existing problems.
Every year around the world, the number of minimally invasive interventions performed by interventional radiologists and doctors of other specialties is increasing. As Dotter predicted, his catheter therapy is increasingly replacing the scalpel. As in 1964, the thesis formulated by Dotter in his article on the first experience remains relevant. interventional treatment: "It can be expected that the transluminal recanalization technique will go beyond the possibilities offered by surgery currently existing" 8 .
Literature:
Abrams' Angiography Vascular and Interventional Radiology. Stanley Baum, M.D., Michael J. Pentercost, M.D. Lippincott-Raven Publishers. 1997.
Mueller RL, Sanborn TA. The history of interventional cardiology: cardiac catheterization, angioplasty, and related interventions. Am Heart J 1995;129:146-72.
Seldinger S.I. Catheter replacement of needle in percutaneous arteriography: new technique. Acta Radiol (Stockh) 1953;39:368.
Geddes LA, Geddes LE. The catheter introducers. Chicago: Mobium Press, 1993.
Rosch J, Abrams HL, Cook W. Memorials: Charles Theodore Dotter, 1920–1985. AJR Am J Roentgenol 1985;144: 1321-3.
Anonymous. Portraits in radiology: Charles T. Dotter, MD. Appl Radiol 1981;10(Jan−Feb):28,116.
Friedman S.G. Charles Dotter: Interventional radiologist. Radiology 1989;172(3 Pt 2):921-4.
Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technic and a preliminary report of its application. Circulation 1964;30:654-70.
Myler R., Stertzer, S. Coronary and Peripheral Angioplasty: Historic Perspective, Textbook of Interventional Cardiology (2nd Ed.) Vol. 1. Topol, E. (Ed.) WB Saunders Co., Philadelphia, 1993
King, S.B. Angioplasty From Bench to Bedside to Bench, Circulation 1996;93:1621-1629
Guide to angiography edited by Professor I. Kh. Rabkin. Moscow. Medicine 1977. 5 - 7
Percutaneous energy ablation of tumors: principles, technologies, results (DOI:10.31917/1703129)
P.V. Balakhnin, A.S. Shmelev, E.G. Shachinov
annotation
Percutaneous energy ablation is promising minimally invasive method of treatment of unresectable primary and metastatic tumors various localizations. The paper discusses the basic principles of interventions, as well as existing technologies used for hyperthermic (laser, ultrasound, radiofrequency and microwave ablation), hypothermic (cryoablation) and non-thermal (photodynamic ablation, irreversible electroporation) ablation of tumors. The main mechanisms of influence are highlighted various kinds energy on tissue, as well as the advantages and disadvantages of their clinical use. The long-term results of treatment of tumors of the liver, kidneys, lungs and tumors of other localizations were analyzed. Modern ideas about the effect of various types of ablation on immune system body, as well potential opportunities the use of ablative technologies in combination with various methods of cancer immunotherapy.
Keywords: radiofrequency ablation , microwave ablation , cryoablation , irreversible electroporation , laser ablation , ultrasound ablation , cancer immunotherapy , interventional radiology
Interventional radiology in oncology: history of development and current state of the problem
B.I. Dolgushin
annotation
For relatively short period existence of interventional radiology today has become an integral part of modern oncology.
The interventional radiologist has a wide range of highly effective minimally invasive radiological and hybrid technologies of various types, including diagnostic and treatment-diagnostic, special antitumor and accompanying technologies, which can be used both independently and combined with other methods of treating cancer patients, often comparable in results. with traditional surgery.
The purpose of this work is to review the possibilities of using a complex of IR and hybrid technologies in oncology. A description of the methods and indications for their implementation is given. The nature and frequency of complications, the feasibility and priority of the clinical application of IR technologies in various fields of practical oncology are considered. Their importance in improving the results of treatment and optimizing the conditions for the rehabilitation of cancer patients, improving economic indicators activities of oncological institutions.
Keywords: interventional radiology, hybrid technologies, vascular/nonvascular IR interventions
Methods of regional therapy of tumors of various localizations
P.G. Tarazov
annotation
The lecture is dedicated to introducing readers to a new promising section clinical oncology– therapeutic X-ray endovascular interventions for malignant tumors of various localizations.
At the beginning of the article, the author substantiates the relevance of the use of regional chemotherapy, focusing on its advantages over existing methods treatment and possibilities of use as a component combination therapy. The main types of interventions used are listed. The following is a description of the mechanisms and effectiveness of X-ray endovascular procedures for tumors of various localizations.
Most often, these procedures are used for liver tumors. Literature data and own results of chemoinfusion, various types of chemoembolization, radioembolization in the treatment of unresectable primary and metastatic cancer liver. The role of pre- and postoperative endovascular procedures is shown.
The application of interventional radiology methods in the treatment of tumors of other localizations is presented: head and neck, lung, breast, organs of the gastrointestinal tract, genitourinary system, musculoskeletal system; own results of treatment are given. It is especially emphasized that it is expedient to use them in combination with other methods of antitumor therapy.
In conclusion, it was noted that the methods of regional therapy play an important role in the treatment of oncological diseases and they should be used more widely. Along with surgery, chemotherapy and radiation, interventional radiology can be considered one of the components of modern clinical oncology.
Key words : interventional radiology , angiography , chemoinfusion , chemoembolization , radioembolization , combined treatment
X-ray surgical methods for the treatment of emergency conditions in oncology
P.V. Balakhnin
annotation
Emergency conditions, directly or indirectly associated with oncological diseases, may be the first manifestation of a malignant tumor in the body, as well as develop at all stages of the treatment of oncological patients. The aim of the work is to consider the possibilities of using various X-ray surgical technologies, such as percutaneous drainage, percutaneous and intraluminal stenting, endovascular interventions and local therapy in the treatment emergency conditions occurring in patients with cancer. The paper considers the possibilities of using the above methods of treatment to eliminate the syndrome of obstruction of hollow organs and tubular structures, perforation of hollow organs and tubular structures, compression of organs in delimited cavities, bleeding, purulent-septic complications, venous thromboembolic complications and severe pain syndrome. It is concluded that X-ray surgery as an independent clinical discipline has a wide range effective technologies that can be used to treat emergency conditions that occur in patients on different stages diagnosis and treatment malignant tumors. Information may be useful to doctors departments of X-ray surgical methods of diagnosis and treatment, as well as all specialists participating in the combined and complex treatment cancer patients.
Interventional radiology is a branch of medical radiology that develops the scientific foundations and clinical application therapeutic and diagnostic manipulations carried out under the control of radiological examination.
Interventions consist of two stages. The first stage includes a radiation study (X-ray television transillumination, computed tomography, ultrasound or radionuclide scanning, etc.), aimed at establishing the nature and extent of the lesion. At the second stage, usually without interrupting the study, the doctor performs the necessary therapeutic manipulations (catheterization, puncture, prosthetics, etc.), which are often not inferior in efficiency, and sometimes even superior to surgical interventions, and at the same time have a number of advantages compared to them. They are more gentle, in most cases do not require general anesthesia; the duration and cost of treatment are significantly reduced; morbidity and mortality are reduced. Interventional interventions can be the initial stage in the preparation of severely weakened patients for the operation required in the subsequent operation.
Indications for interventional interventions are very wide, which is associated with a variety of tasks that can be solved using the methods of interventional radiology. General contraindications are the serious condition of the patient, acute infectious diseases, mental disorders, decompensation of the functions of the cardiovascular system, liver, kidneys, when using iodine-containing radiopaque substances - hypersensitivity to iodine preparations.
Preparation of the patient begins with explaining to him the purpose and methodology of the procedure. Depending on the type of intervention, different forms of premedication and anesthesia are used. All interventional interventions can be conditionally divided into two groups: X-ray endovascular and extravasal.
X-ray endovascular interventions, which have received the greatest recognition, are intravascular diagnostic and therapeutic manipulations carried out under X-ray control. Their main types are X-ray endovascular dilation, or angioplasty, X-ray endovascular prosthetics and X-ray endovascular occlusion.
vascular interventions.
1. Arterial angioplasty in peripheral and central vascular pathology.
This range of interventions includes balloon dilatation of arteries, vascular stenting, atherectomy. With obliterating diseases of the lower extremities, it often becomes necessary to restore the lumen of the affected vessels in order to eliminate ischemia. For this purpose, in 1964, Dotter and Judkins began to use a set of coaxial catheters for bougienage of the lumen of the arteries. But the greatest progress was made after the introduction of a special balloon catheter in 1976 by Gruntzig. Inflating the balloon, installed in the place of narrowing of the vessel, leads to the restoration of its lumen either in full or in sizes that allow to provide adequate nutrition limbs. In addition, there is the possibility of multiple dilations. In subsequent years, balloon dilations began to be used on brachiocephalic, coronary, renal, mesenteric arteries, hemodialysis fistulas. However, the inevitable traumatization of the intima, its subsequent hyperplasia, gives a high percentage of restenoses. In this regard, intravascular metal or nitinol prostheses - stents - have been developed. There are several modifications of stents, which can be divided into self-expanding and balloon expandable. Accordingly, the method of their implantation also differs. Wallstent placement is preceded by balloon dilatation, and with balloon expandable stents, this occurs simultaneously. Moreover, the use of polyethylene-coated stents allows them to be used for the treatment of aneurysms of the aorta and large arteries (including fusiform and aneurysms large sizes) by creating a new vessel lumen. In recent years, stenting of the vena cava with their compression by tumors, as well as any hollow tubular structures, such as the esophagus, pylorus, biliary tract, intestines, trachea and bronchi, ureters, nasolacrimal canal, has been used. The main indications for such procedures are malignant inoperable tumors. Despite the palliative nature, dysphagia, esophago-respiratory fistulas, obstructive jaundice, intestinal obstruction, urostasis.
2. The fight against pathological thrombosis.
Currently, regional thrombolysis has become widely used. Placement of the catheter as close as possible to the thrombus allows to increase the efficiency and reduce the doses of fibrinolytic drugs administered through it, thereby reducing the side effects of such treatment. Some companies have developed systems for intravascular mechanical thrombus retraction and suction of fresh clots. The most effective method of combating pulmonary embolism is the installation of metal filters in the inferior vena cava. This creates an obstacle in the way of large migrating blood clots. To install the filter, either transfemoral or transjugular access is used, special system installation and delivery of the filter. Filters differ in their modification. The best known are the Gunther-Tulip and Bird's Nest filters from William Cook Europe, and the Greenfield filter from Medi-Tech/Boston Scientific.
3. Vascular embolizations.
This type of intervention is used to stop bleeding of various localization, treat a number of tumors, as well as for some aneurysms and vascular anomalies. As embolizing agents, oily contrast agents, hemostatic gelatin sponge, Ivalon, sotradecol, 96% ethyl alcohol, metal spirals, autohemoclots, microspheres with ferromagnets, etc. are used. Embolization with a hemostatic purpose is very effective for gastrointestinal bleeding, severe pelvic injuries, bleeding tumors of the lung, kidney, bladder and female genitalia.
The method of chemoembolization of the hepatic artery is widely used in malignant primary and metastatic liver tumors. Here, the properties of oily contrast agents (lipiodol, etiodol, etiotrast, mayodil and iodolipol) have found application. When injected into the hepatic artery, they penetrate and deposit much more actively in the tumor tissue than in the hepatic parenchyma. Mixed with cytostatics (most often with doxorubicin), they have not only an ischemic, but also a chemotherapeutic effect. Some authors consider chemoembolization of the hepatic artery as an alternative to liver resection in case of solitary tumor lesions, and in case of multiple liver metastases, although palliative, but the only way to prolong the life of the patient and its quality.
Among other pathologies in which embolization is effective, it should be noted arteriovenous malformations, aneurysms of cerebral vessels with a clearly defined neck, some tumors of the musculoskeletal system, an open ductus arteriosus.
The abbreviation TIPS stands for Transjugular Intrahepatic Portal Vein System Shunt. The technique was proposed by Rusch to combat bleeding from esophageal varices in portal hypertension. After puncture jugular vein and its catheterization, the catheter is installed in one of the hepatic veins, and then one of the branches of the portal vein is punctured with a special needle passed through the catheter. The completed tunnel is expanded with a balloon catheter and stented. The result of the procedure is an artificially created porto-caval anastomosis through just one puncture hole.
5. Extraction of foreign bodies.
With the help of catheters with loop-traps, baskets and other devices, X-ray surgeons can correct the flaws in their work or the consequences of the interventions of surgeons and anesthesiologists in the form of fragments of catheters, conductors, and other foreign bodies left in the lumen of blood vessels and cavities of the heart. After the foreign body is captured by the fixing element of the catheter, it is lowered into a peripheral vessel, most often into the femoral artery or vein, and removed through a small incision.
Extravasal interventions include endobronchial, endobiliary, endoesophageal, endourinal and other manipulations.
