The number of palliative procedures available to the interventional radiologist has rapidly expanded during recent years, and the need for continued implementation and innovation in this space is at an all-time high. The overuse of opioid analgesics has created a serious public health crisis, and the United States Centers for Disease Control and Prevention has called upon physicians to develop nonpharmacologic therapies for pain, stating clearly that procedures with adequate evidence of safety and efficacy are preferable to opioids for the management of chronic pain. As interventional radiologist, we are uniquely equipped to deliver existing solutions and develop new alternatives through the application of advanced imaging guidance. Moreover, multiple percutaneous techniques have independently evolved in recent years for the management of cardiac and cancer-related pain.

Non-Invasive Services

Cancer Chemoembolization

How is liver cancer treated?

Malignant tumors of the liver or gastrointestinal tract which have spread to the liver may be treated by standard intravenous chemotherapy, surgery, cryotherapy (using cold probes to freeze the tumor), percutaneous ablation (using a needle to place alcohol directly into the tumor to kill it), or a combination of therapeutic techniques. A method of delivering a relatively large dose of chemotherapy directly to the liver tumor (chemoembolization) has shown some good results in patients who are not candidates for standard therapy.

What is chemoembolization?

Chemoembolization is performed by placing a small catheter from the blood vessel in your groin into the artery that supplies blood to the liver. This is analogous to the more familiar cardiac angiogram. The chemotherapeutic drug(s) are then delivered through the catheter along with a blood vessel occluding agent right at the site of the tumor. The result is that a very highly concentrated dose of anti-tumoral drug is delivered (without the normal dilution that occurs with a standard intravenous infusion) and the blood vessels are partially blocked with the occluding agent to starve the tumor of it’s blood supply. This “double-punch” can slow or stop tumor growth, and in some cases can even result in significant shrinkage of the tumor. If you are interested in further information on this technique or believe you might be candidate, please contact us.

What kind of tumors can be treated?

Remember, chemoembolization only treats tumors in the liver and will have little or no effect on any other cancer in the body. For example, the following liver cancers may be treated by chemoembolization:

• hepatoma (primary liver cancer)
• metastasis (spread) to the liver from:
• colon cancer
• carcinoid
• ocular melanoma
• sarcomas
• a primary tumor in another part of the body

How are patients evaluated?

Your physician may recommend that you have several tests, including liver function blood tests, and a CAT scan or an MRI of your liver prior to the chemoembolization procedure. Your doctor needs to check these test results to make sure you do not have:

• any blockage of the portal vein
• cirrhosis of the liver
• a blockage of the bile ducts

If you have any of these complications, your doctor may not allow you to have the Chemoembolization procedure.

Arterial Uterine Embolization

Overview

Uterine artery embolization is a minimally invasive treatment for uterine fibroids, noncancerous growths in the uterus. In uterine artery embolization — also called uterine fibroid embolization — a doctor uses a slender, flexible tube (catheter) to inject small particles (embolic agents) into the uterine arteries, which supply blood to your fibroids and uterus. The goal is to block the fibroid blood vessels, starving the fibroids and causing them to shrink and die.

Why it’s done

Uterine fibroids can cause severe symptoms in some women, including heavy menstrual bleeding, pelvic pain and swelling of the abdomen. Uterine artery embolization destroys fibroid tissue and eases these symptoms. And it provides an alternative to surgery to remove fibroids (myomectomy).
You might choose uterine artery embolization if you’re premenopausal and:

• You have severe pain or heavy bleeding from uterine fibroids
• You want to avoid surgery, or surgery is too risky for you
• You want to keep your uterus
• Optimizing a future pregnancy isn’t your chief concern

Risks

Rarely, major complications occur in women undergoing uterine artery embolization. The risk of complications from uterine artery embolization is about the same as those for surgical treatment of fibroids. These may include:

• Infection. A degenerating fibroid can provide a site for bacterial growth and lead to infection of the uterus (endomyometritis). Many uterine infections can be treated with antibiotics, but in extreme cases, infection may require a hysterectomy.
• Damage to other organs. Unintended embolization of another organ or tissue can occur, although it’s not as high a risk as with surgery. Whether you have embolization or surgery, disruption of the ovarian blood supply is a possibility because the ovaries and uterus share some blood vessels. If you’re nearing menopause (perimenopausal), such a disruption could lead to menopause ― but that’s rare if you’re age 40 or younger.
• Possible problems in future pregnancies. Many women have healthy pregnancies after having uterine artery embolization. However, some evidence suggests pregnancy complications, including abnormalities of the placenta attaching to the uterus, may be increased after the procedure.

If you want to have children, talk to your doctor about the risks of surgery and how uterine artery embolization might affect your fertility and future pregnancy.
Reasons to avoid this procedure
Avoid uterine artery embolization if you:

• Are pregnant
• Have possible pelvic cancer
• Have an active, recent or chronic pelvic infection
• Have a condition that affects your blood vessels (vascular disease)
• Are allergic to contrast material containing iodine

Most fibroid sizes and locations can be treated with uterine artery embolization. However, extremely large fibroids can be so big that they cause complications and require another method to remove them.

Some fibroids that are primarily inside the uterus (pedunculated submucosal) may be expelled vaginally following the procedure. Finally, if the fibroids have already lost their blood supply (degenerated), uterine artery embolization won’t provide any benefit.

Discuss the benefits and risks of uterine artery embolization with your obstetrician-gynecologist or an interventional radiologist ― a doctor who uses imaging techniques to guide procedures that would be impossible with conventional surgery.

How you prepare

Uterine artery embolization usually is performed by an interventional radiologist or a specialist in obstetrics and gynecology who has training in uterine artery embolization.
Food and medications
On the evening before the procedure, don’t eat or drink after midnight or after whatever time your doctor advised. If you’re taking medications, ask your doctor if you should stop taking them before or after the procedure.

What you can expect

To see your uterus and blood vessels, the radiologist uses a fluoroscope. This device is a pulsed X-ray beam that produces moving images of internal structures and displays them on a computer monitor.

Catheterization

Before the procedure

In the radiology procedure room, you’ll have an intravenous (IV) line placed in one of your veins to give you fluids, anesthetics, antibiotics and pain medications.

Uterine artery embolization

During the procedure

The procedure includes:

• Anesthesia. Typically you’ll receive a type of anesthesia that reduces pain and helps you relax, but leaves you awake (conscious sedation).
• Blood vessel access. The doctor makes a small incision in the skin over your femoral artery, a large blood vessel that passes lengthwise through your groin. Then your doctor inserts a catheter into the artery and guides the catheter to one of the two uterine arteries. Generally, the doctor can access both uterine arteries through one incision.
• Blood vessel mapping and injection. An injected contrast fluid, usually containing iodine, flows into the uterine artery and its branches and makes them visible on the fluoroscope’s monitor. The fibroids “light up” more brightly than other uterine tissue.

The radiologist identifies the right area of the uterine artery and then injects the blood vessel with tiny particles made of plastic or gelatin. The particles are carried by the blood flow to block the fibroid vessels.

After injecting more contrast into the uterine artery, the doctor checks additional images to make sure that blood is no longer reaching the fibroids. The same steps are then repeated in the second uterine artery.

After the procedure

In the recovery room, your care team monitors your condition and gives you medication to control any nausea and pain. When the effects of the anesthesia fade, they take you to your hospital room for overnight observation.

• Position. You must lie flat for several hours to prevent pooling of the blood (hematoma) at the femoral artery site.
• Pain. The primary side effect of uterine artery embolization is pain, which may be a reaction to stopping blood flow to the fibroids and a temporary drop in blood flow to normal uterine tissue. Pain usually peaks during the first 24 hours. To manage the pain, you receive pain medication.
• Observation. Post-embolization syndrome — characterized by low-grade fever, pain, fatigue, nausea and vomiting — is frequent after uterine artery embolization.

Post-embolization syndrome symptoms peak about 48 hours after the procedure and usually resolve on their own within a week. Ongoing symptoms that don’t gradually improve should be evaluated for more-serious conditions, such as an infection.

By the next day, your urinary catheter is removed, and you’re encouraged to walk around. Recovery is generally rapid, and complications are rare.

Recovery

Most women return home the day after the procedure with a prescription for oral pain medication. Pain usually ends within a day or two, but in some women it may last up to a few weeks.

Monitor your recovery for:

• Vaginal discharge. You might have a watery or mucus-like vaginal discharge for a few weeks to a month after uterine artery embolization. The discharge should stop without treatment. In a few women, remnants of fibroids are passed through the vagina.
• Infection. Return to your obstetrician-gynecologist or primary care doctor for a follow-up exam within four weeks of the procedure to make sure there’s no infection. Signs and symptoms of infection include fever, chills and pain. Delayed infections and vaginal discharge are rarely reported weeks to months after the procedure.

Follow-up

You may have a magnetic resonance imaging (MRI) exam over the next year to monitor shrinkage or other changes in the fibroids or your uterus. Doctors usually schedule the first exam three months after the procedure.

Results

Uterine artery embolization typically provides significant relief of symptoms. It also affects your menstrual period and it may have an impact on fertility.

• Symptom relief. Most women get significant symptom relief in the first three months after treatment. In addition, some research shows that five years after treatment uterine artery embolization continues to reduce symptoms such as heavy bleeding, urinary incontinence and abdominal enlargement in most women. These results appear to be comparable to that of myomectomy, in which the fibroids are surgically removed and the uterus repaired.
• Menstruation. Your menstrual period may continue on its normal schedule. If you miss any periods, they will probably resume within a few months.
• A small number of women enter menopause after the procedure. The risk appears highest among women age 45 and older.
• Impact on fertility. Although the risk of entering menopause after the procedure is low, subtle ovarian damage may make getting pregnant more difficult. There also may be an increased risk of pregnancy complications, especially involving abnormal placement or attachment of the placenta. Despite these risks, many women have had successful pregnancies after uterine artery embolization.

But, more long-term, larger studies are needed to determine the impact of uterine artery embolization on fertility and pregnancy — and the risks of uterine artery embolization must also be compared with the risks of surgery.

Coil Embolizations

What is Embolization?

Healthcare providers use endovascular coiling, also called endovascular embolization, to block blood flow into an aneurysm. An aneurysm is a weakened area in the wall of an artery. If an aneurysm ruptures, it can cause life-threatening bleeding and brain damage. Preventing blood flow into an aneurysm helps to keep it from rupturing.

For endovascular coiling, healthcare providers use a catheter, a long, thin tube inserted into a groin artery. The catheter is advanced into the affected brain artery where the coil is deployed. X-rays help guide the catheter into the artery. The coils are made of soft platinum metal, and are shaped like a spring. These coils are very small and thin, ranging in size from about twice the width of a human hair to less than one hair’s width.
Healthcare providers also use coiling to treat a condition called arteriovenous malformation, or AVM. An AVM is an abnormal connection between an artery and a vein. It may happen in the brain, spinal cord, or elsewhere in the body.

Why might I need endovascular coiling?

Healthcare providers most commonly use coiling to treat a cerebral aneurysm at risk for rupturing. In some cases, they may use it to repair a ruptured aneurysm.
There may be other reasons for your healthcare provider to recommend a coiling procedure.

What are the risks of endovascular coiling?

If you are pregnant or think you may be pregnant, you should tell your healthcare provider.
There is a risk for allergic reaction to the dye injected to allow the aneurysm to be viewed on X-ray. People who are allergic to or sensitive to medicines, contrast dye, or iodine should tell the radiologist or technologist. People with kidney failure or other kidney problems should tell the radiologist.
People who take anticoagulant (blood-thinning) medicines, such as aspirin, warfarin, clopidogrel, or others, should tell their healthcare providers before the procedure. These medicines may be stopped for one or more days before the procedure.
Because the procedure involves the blood vessels and blood flow of the brain, there is a risk for complications involving the brain. These complications may include:

• Loss of consciousness
• Stroke or transient ischemic attack (TIA, a temporary stroke-like condition)
• Paralysis of one half of the body
• Blood clot
• Bleeding
• An area of swelling caused by a collection of blood (hematoma)
• Loss of the ability or speak or the ability to understand speech (aphasia)
• Infection
• Rupture of unruptured aneurysm
• Higher chance of an aneurysm recurring

There may be other risks depending on your specific medical condition. Discuss any concerns with your healthcare provider before the procedure.

How do I get ready for an endovascular coiling?

• Your healthcare provider will tell you about the procedure and offer you a chance to ask any questions.
• You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
• Tell your healthcare provider if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.
• Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, or anesthetic agents (local and general).
• You will need to fast for a certain period before the procedure. Your healthcare provider will tell you how long to fast, whether for a few hours or overnight.
• Tell your healthcare provider if you are pregnant or think you may be pregnant.
• Tell your healthcare provider of all medicines (prescribed and over-the-counter) and herbal supplements that you are taking.
• Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medicines, aspirin, or other medicines that affect blood clotting. It may be necessary for you to stop these medicines before the procedure.
• Your healthcare provider may request a blood test before the procedure to determine how long it takes your blood to clot. Other blood tests may be done as well.
• Based on your medical condition, your healthcare provider may request other specific preparation.

What happens during an endovascular coiling?

You will need to stay in the hospital for a coiling procedure. Procedures may vary depending on your condition and your healthcare provider’s practices.
Your procedure may be done by one or both of these specialists:
Neurosurgeon. This healthcare provider specializes in surgery and treatment of the nervous system
Interventional radiologist. This healthcare provider specializes in diagnostic and treatment methods using radiology techniques.
During the procedure, you are asleep under general anesthesia. In some situations, it may be done under local anesthesia.
Generally, a coiling procedure follows this process:

• You will be asked to remove any clothing, jewelry, hairpins, dentures, or other objects that may interfere with the procedure, and will be given a hospital gown to wear.
• You will be given time to empty your bladder prior to the start of the procedure.
• You will be positioned on your back on the X-ray table.
• An intravenous (IV) line will be started in your hand or arm.
• You will be connected to an electrocardiogram (ECG) monitor that records the electrical activity of the heart. Your vital signs (heart rate, blood pressure, and breathing rate) and neurological signs will be monitored during the procedure.
• A catheter may be inserted into your bladder to drain urine.
• The radiologist or neurosurgeon will check your pulses below the groin site where the catheter will be inserted and mark them with a marker so that the circulation to the limb below the site can be checked after the procedure.
• The skin over the injection site will be cleansed. A local anesthetic will be injected.
• A small incision will be made in the skin to expose the artery in the groin.
• A catheter will be inserted into the artery in your groin using a guide wire. The catheter will be guided through the blood vessel into the brain using fluoroscopy (a special type of X-ray, similar to an X-ray “movie”).
• Once the catheter has been guided to the affected artery in the brain, contrast dye will be injected to make the aneurysm and surrounding blood vessels visible on X-ray.
• The aneurysm will be measured and its shape and other characteristics will be recorded.
• Next, a smaller catheter will be inserted into the initial catheter.
• Once the catheter has reached the aneurysm, the healthcare provider will manipulate the coil into the aneurysm.
• When the coil has been completely inserted into the aneurysm, the coil is separated from the catheter.
• The healthcare provider will insert as many coils as needed to completely seal off the aneurysm. The coils will form a mesh-like structure inside the aneurysm.
• After the aneurysm has been “packed” with coils, additional X-ray images will be taken to make sure the aneurysm has been sealed off. The coil is left in place permanently in the aneurysm.
• Once the aneurysm has been sealed off, the catheter will be removed. After the insertion site stops bleeding, a dressing will be applied.

What happens after an endovascular coiling?

In the hospital

After the procedure, you may be taken to the recovery room or the intensive care unit (ICU) for observation. If the coiling procedure was done for a ruptured aneurysm, you will most likely be taken to the ICU for recovery and observation. If the coiling procedure was done for an unruptured aneurysm and your condition is otherwise stable, you may be able to go home a day or two after the procedure.
You will remain flat in bed for as long as 12 to 24 hours after the procedure. A nurse will monitor your vital signs, neurological signs, the insertion site, and circulation or sensation in the affected leg.
You may be given pain medicine for pain or discomfort from the procedure or from having to lie flat and still for a prolonged period.
You may resume your usual diet after the procedure, unless your healthcare provider decides otherwise.
Once you have recovered, you may be able to go home, unless your healthcare provider decides otherwise. In some cases, after a procedure for a ruptured aneurysm, a transfer to a rehabilitation facility may be necessary to help continue recovery from damage that may have happened as a result of the ruptured aneurysm.

At home

You may be advised not to do any strenuous activities. Your healthcare provider will instruct you about when you can return to work and resume normal activities. Tell your healthcare provider if you experience any of the following:

• Fever and/or chills
• Increased pain, redness, swelling, or bleeding or other drainage from the insertion site
• Coolness, numbness and/or tingling, or other changes in the affected extremity
• Any changes in bodily functions or neurological changes, such as extreme headache, seizure, or loss of consciousness

Generally, a cerebral angiogram will be done periodically after the procedure make sure the coiling is working. The first angiogram may be done about one month after the procedure. Additional cerebral angiograms and/or other imaging procedures, such as MRI or MRA may be done at intervals to be determined by your healthcare provider based on your condition and the results of previous post-coiling imaging procedures.

Your healthcare provider may give you other specific instructions about what you should do after an endovascular coiling.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure
• The reason you are having the test or procedure
• What results to expect and what they mean
• The risks and benefits of the test or procedure
• What the possible side effects or complications are
• When and where you are to have the test or procedure
• Who will do the test or procedure and what that person’s qualifications are
• What would happen if you did not have the test or procedure
• Any alternative tests or procedures to think about
• When and how will you get the results
• Who to call after the test or procedure if you have questions or problems
• How much will you have to pay for the test or procedure

US & CT Guided Biopsies

CT guided biopsy

CT guided biopsy is a type of image-guided biopsy. It is generally less commonly used than ultrasound-guided biopsy, however, in some anatomical areas, it has greater precedence, such as lung and bone biopsies.

CT guided biopsy requires good teamwork with radiographic staff as it is not truly dynamic like ultrasound-guided biopsies.

It may be performed using the ‘CT fluoroscopy’ capabilities of modern CT scanners or with the traditional step-wise approach.

CT biopsies are usually performed using a co-axial needle technique to gain a stable position through which the biopsy may be performed.

Most common percutaneous biopsies

• CT guided thoracic biopsy
• CT guided bone biopsy
• CT guided adrenal biopsy
• Image-guided percutaneous renal biopsy

Ultrasound-guided biopsy

Ultrasound-guided biopsy is one form of image-guided biopsy, typically performed by a radiologist. It is the most common form of image-guided biopsy, offering convenience and real-time dynamic observation with echogenic markers on cannulae allowing for precise placement.

It can potentially be used to perform a biopsy of any body part, being regularly used to biopsy the kidney, liver, breast and lymph nodes. There can be some minor procedural variation in the type of biopsy performed.
Biopsies may be focal or non-focal in nature. Lesions as small as 5 mm may be biopsied, with a range of biopsy needle gauges and sizes available (from 22G to 14G). Broadly speaking needles may be single or co-axial and have 10 mm or 20 mm cutting lengths.

Most common percutaneous biopsies

• ultrasound-guided renal biopsy
• ultrasound-guided breast biopsy
• ultrasound-guided liver biopsy
• ultrasound-guided biopsy of a peripheral soft tissue mass

Invasive Services

Fistulagrams

What is a fistulagram?

A fistula is a passage from your kidney that allows kidney dialysis. A fistulagram is an X-ray procedure to look at the blood flow and check for blood clots or other blockages in your fistula.

Why is it necessary?

Blood clots or blockages may interfere with your dialysis. The fistulagram helps the doctor find any blockages.

How is it done?

The radiologist places tiny tubes, called catheters, in your fistula, much like what occurs during dialysis. The doctor then injects special dye so it can be seen on X-rays.
Before the procedure:

• You must not to eat or drink anything after midnight the night before the study except for your normal medications. Your doctor or nurse will tell you if you should stop taking any of your medications prior to the procedure.
• You need to bring a list of all your medications with you to the hospital.
• Please tell the doctor if you think you may be pregnant.
• A nurse will place an IV in your hand or arm so that you can receive fluids and medications.
• Your doctor will answer your questions and ask you to sign a consent form.

During the procedure:

• You will lie on an x-ray table with machines all around you. You will have a blood pressure cuff on your arm, a clip on your finger to make sure you are getting enough oxygen, and wires on your legs and arms to check your heart rate.
• The nurse will give you pain medication and a sedative, which will help you relax, before the procedure. The nurse will give you more medication if needed. You will feel relaxed, but you will be awake so that you can follow instructions.
• The area where the doctor will be working will be cleaned and shaved. You will be covered with sterile drapes from your shoulders to your feet.
• The doctor will insert small catheters into your fistula and may inject blood thinners.
• The doctor will inject the dye. The technologists working with your doctor will take X-ray pictures.

After the procedure:

• You will go to the recovery room, where the nurse will check you blood pressure, heart rate, and fistula.
• When the blood thinners have worn off, the catheters will be removed. The nurse will apply pressure to the site to prevent bleeding.
• If you are an outpatient, you may leave after a short recovery period. You will need someone to drive you home.
• Procedure and recovery times vary greatly from patient to patient. The time needed depends on how big and where the blockage is in the fistula, and how long it takes for the blood thinners to wear off. You may be at the hospital most of the day.

After you go home:

• You may drive after 24 hours.
• You may resume normal activities the next day.

PTA & Stent of Fistulas

Minimally invasive, endovascular procedures such as angioplasty can reduce risk and offer shorter recovery times, compared to open surgery.

Angioplasty is sometimes done alone, without stenting.

Your doctor will choose a therapy based on your ability to exercise, your risk of open surgery, and the type, number and degree of blockage(s).

Angioplasty (Percutaneous Transluminal Angioplasty)

• Angioplasty may be performed for coronary artery disease or peripheral artery disease. When it is performed for peripheral arty disease, the procedure is called percutaneous transluminal angioplasty (PTA).
• At the start of the procedure, a thin tube called a catheter enters the femoral artery through a small puncture in the thigh.
• Your physician uses X-rays to guide the catheter to the blockage, then inflates a balloon at the tip of the catheter.
• The balloon presses the clogging material flat against the artery wall, expanding the artery and allowing more space for the blood to flow.
• Your physician may use a plain balloon or one coated with medication (drug-eluting balloon), which helps prevent scarring while the artery heals.

Stenting

• A stent is a tube of metal mesh that holds your artery open and may improve the results of angioplasty alone.
• In a minimally invasive, endovascular procedure, a catheter delivers the stent to the blockage site.
• Stents can be bare metal, covered with fabric and/or coated with medication (drug-eluting stent), which helps prevent scarring while the artery heals.
• Stents may also be placed as part of open surgery.

Declotting of Fistulas

Dialysis fistula/graft declotting interventions improve blood flow in fistula and grafts – artificial blood vessel connections used to facilitate kidney dialysis, a treatment that uses a special machine to remove waste materials from the body. These connections can clog or narrow and require angioplasty and vascular stenting or catheter-directed thrombolysis.

Your doctor will tell you how to prepare and whether you will be admitted to the hospital. Inform your doctor if there’s a possibility you are pregnant and discuss any recent illnesses, medical conditions, allergies and medications you’re taking. You may be advised to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners several days prior to your procedure. Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown.

What are Dialysis and Fistula/Graft Declotting and Interventions?

Dialysis fistula/graft declotting and interventions are minimally invasive procedures performed to improve or restore blood flow in the fistula and grafts placed in the blood vessels of dialysis patients.
Dialysis is a process used to treat patients whose kidneys are not working properly. It involves a special machine and tubing that removes blood from the body, cleanses it of waste and extra fluid and then returns it back to the body.
In order for a person to undergo dialysis, a physician first creates access to his or her blood vessel using one of three methods:

• a fistula, which is made by joining together an artery and vein to make a bigger high-flow blood vessel.
• a graft, in which a soft plastic tube is placed between an artery and a vein, creating an artificial high-flow blood vessel.
• catheter access, in which a narrow plastic tube is inserted into a large vein in the neck or groin.
  When fistulas and grafts become clogged or narrowed, which can prevent a patient from undergoing dialysis, interventional radiologists use image-guided interventions to fix the problem:
• Catheter-directed thrombolysis, which dissolves blood clots that build up in fistulas and grafts by injecting a medicine.
• Catheter-directed mechanical thrombectomy, where the clot is physically removed or mashed up.
• Angioplasty and vascular stenting, which use mechanical devices, such as balloons, to open fistulas and grafts and help them remain open. After the balloon is removed, a small wire mesh tube called a stent may be implanted to keep the fistula or graft open if angioplasty alone fails.

Kyphoplasty

Like vertebroplasty, kyphoplasty injects special cement into your vertebrae — with the additional step of creating space for the treatment with a balloon-like device (balloon vertebroplasty). Kyphoplasty can restore a damaged vertebra’s height and may also relieve pain.

As with vertebroplasty, the effectiveness of kyphoplasty is under debate in the medical community — you should discuss the risks and benefits with your doctor.

Doctors might recommend kyphoplasty for cancer-damaged vertebrae or certain spinal fractures. In most cases, a weakening of the bones (osteoporosis) has caused the vertebrae to compress or collapse, causing pain or a hunched posture.

Kyphoplasty Risks

The risks of kyphoplasty include:

• Infection
• Bleeding
• Increased back pain
• Tingling, numbness or weakness because of nerve damage
• Allergic reactions to chemicals used with X-rays to help guide the doctor
• Cement leaking out of position

You may face other risks, depending on your specific medical condition. Make sure to discuss any concerns with your doctor before the procedure.

How Kyphoplasty Works

Before the procedure:

• Your doctor will examine you, possibly drawing blood for testing and using X-ray or magnetic resonance imaging (MRI) to locate the fractures.

During the procedure:

• An anesthesiologist will deliver medicine through an IV to either relax you and relieve your pain or put you to sleep.
• With X-ray guidance, your doctor will insert a needle through your skin and back muscles into the bone, then inflate a balloon to help the vertebra regain its normal shape.
• Your doctor will inject the cement while checking X-rays to ensure it’s going into the right place.
• Your doctor will remove the needle, with no stitches needed.
• The entire procedure will probably take less than an hour, though it may last longer if more vertebrae are treated.

After the procedure:

• You will spend time in a recovery room. You could go home the same day, but your doctor may want you to stay overnight.
• It’s possible that you can start walking an hour after the procedure. You may feel some soreness where the needle entered your back, but this lasts no more than a few days. You may quickly notice that you have less pain than you did before the surgery.
• Talk with your doctor about whether you should avoid any activities after the procedure.
• Your doctor may suggest taking certain vitamins, minerals and medications to help strengthen your bones and prevent additional spinal fractures.

Nerve Block

A nerve block is an injection to decrease inflammation or “turn off” a pain signal along a specific distribution of nerve. Imaging guidance may be used to place the needle in the most appropriate location for maximum benefit. A nerve block may allow a damaged nerve time to heal, provide temporary pain relief and help identify a more specific cause of pain.

This procedure requires little to no special preparation. Tell your doctor if there’s a possibility you are pregnant. Wear loose, comfortable clothing and leave jewelry at home. You may be asked to wear a gown.

What is a Nerve Block?

A nerve block is an anesthetic and/or anti-inflammatory injection targeted toward a certain nerve or group of nerves to treat pain. The purpose of the injection is to “turn off” a pain signal coming from a specific location in the body or to decrease inflammation in that area.
Imaging guidance, such as fluoroscopy or computed tomography (CT or “CAT” scan), may be used to help the doctor place the needle in the most appropriate location so that the patient can receive maximum benefit from the injection.

How should you prepare for the procedure?

Usually, no special preparation is required prior to arrival for a nerve block procedure.
You may need to wear a gown during the procedure.
You will probably be asked to use the restroom before the procedure.
You will then be positioned on your stomach, back or side on a special fluoroscopic or CT table that will give the doctor easiest access to the injection site(s). The nurse will help to make you as comfortable as possible, both during and after the procedure.

How is the procedure performed?

This procedure is often done on an outpatient basis. However, some patients may require admission following the procedure. Ask your doctor if you will need to be admitted.

Nerve blocks usually take only minutes to administer.

You will be positioned on a table or other surface to allow the doctor access to the site(s) to be injected. The doctor will then identify the spot the needle needs to be placed, using palpation and/or imaging guidance. He or she will clean the area with antiseptic solution, and then the needle will be inserted at a specific depth to deliver the medication as close to the problematic nerve(s) as possible. Contrast material may be injected to confirm needle position prior to injection of medicine.

More than one injection may be required, depending on how many areas of pain you have or how large an area needs to be covered. The doctor will most likely tell you when he or she inserts the needle and when the injection is done.

When finished, you will be allowed to rest for 15 to 30 minutes to let the medication take effect. The nurse will also make sure you don’t have any unexpected side effects before you leave the doctor’s office.

What will I experience during the procedure?

You will probably feel a “pinch” when the needle is inserted. As soon as the medication is delivered, though, you should feel less discomfort. Sometimes the needle has to be inserted fairly deep to reach the nerve causing your problem. This can be temporarily uncomfortable, but it is important to hold still so that the needle is inserted correctly.
If you require an injection close to a major nerve or bundle of nerves, such as the sciatic nerve, your doctor will tell you to speak up if you get a sudden jolt of pain. This means that the needle has come too close to the major nerve and will need to be retracted and re-positioned. This happens rarely, however, so it should not be a major concern.
After the injection, you will probably experience a sensation of pain relief in the area injected. This will typically last up to one or two weeks, or even permanently in some cases.

Who interprets the results and how do I get them?

A radiologist or anesthesiologist will most likely perform the nerve block injection.
The doctor who delivers the injections will follow up with you to see how you are doing and determine if further action is required. Any imaging that is performed during the procedure itself will conclude with the procedure, and no follow-up image interpretation is necessary.