INTERVENTIONAL RADIOLOGY

Lesson 1: Introduction to Interventional Radiology 2. Angiogram film shows exactly same anatomic details,
if the patient does not move, plus the opacified blood
Surgery
vessels.
• more painful 3. If all the information in the scout film could be
• longer recovery time subtracted from the angiogram film, only the opacified
• more expensive vessel pattern would remain visible.
Interventional Radiology Note: Aside from bones, tumors can also obscure the
• less painful anatomy of interest. However, hindi ito gaano nagpag-
• shorter recovery time (6 hours) uusapan dahil walang ganoong kalalaking tumor sa
• less expensive usual AOI.
• uses needles and guide wires with the aid of
imaging

Examples: pleural effusion – draining; narrowing of

heart vessels – cardiac catheterization under
fluoroscopy (continuous x-ray emission, live images)

--- Interventional Radiology ---

a medical specialty that uses medical imaging

techniques like ultrasound, computed tomography,
magnetic resonance imaging, and x-ray fluoroscopy to
carry out a variety of minimally invasive operations.

Note: If MRI is used, we need non-magnetic needles.

❑ Digital Subtraction Angiography A DSA machine is simply a fluoroscopy machine.

➢ Angio – blood vessel Note: Hospitals in PH that are internationally accredited
➢ Angiography – the radiological study of blood through Joint Commission International (JCI) are: St.
vessel in the body after the introduction of an Lukes MedCen, Makati MedCen, Cardinal Santos*, and
iodinated contrast media The Medical City.
➢ Subtraction - a technique by which bone
structures images are subtracted o cancelled The Imaging Chain
out from a film of bones plus opacified vessels,
❑ The X -ray Generator
leaving an unobscured image of the vessels
o a device that acts as the primary control
Therefore, DSA is the acquisition of digital fluoroscopic
mechanism for the entire fluoroscope
images combined with injection of contrast material
o through the X-ray generator that current is
and real time subtraction of pre- and post-contrast
allowed to flow into the X-ray tube
images to perform angiography.
o an electrical current is applied to the x-ray
Note: Circle of Willis is the main artery in the head generator which will then flow to the tube for
the x-rays to be produced and emitted
Note: A guide wire costs a hundred thousand. This is still
cheaper than undergoing a surgery. Generator Types

The principles of subtraction are based on the ➢ single phase – has 2 coils
following: ➢ three phase – has 6 coils

1. Scout film shows the structural details of the skull and

the adjacent soft tissue.

- scout film is a normal radiograph; we check first the

positioning and the technical factor
 INTERVENTIONAL RADIOLOGY

➢ constant potential The X-ray Tube Components

➢ high frequency – the most commonly used in
o the glass envelope
new radiographic equipment as it provides
o made of Pyrex glass which is able to
superior exposure reproducibility along with
withstand tremendous heat
the most compact size, lowest purchase price,
and lowest repair costs
o tube maintains a vacuum

o has the so called the tube window

which is thinner than the rest of the
glass envelope

o contributes to the inherent filtration of

0.5 mm Al equivalency

o cathode (the negatively charged electrode)

o has the filament – a small coil of
thoriated tungsten

o has the focusing cup – a negatively

charged, shallow depression on the
surface of the cathode of an x-ray tube,
which concentrates the electron beam
towards the focal spot of the anode

o anode (the positively charged electrode)

o may be stationary – made of tungsten
target; usually used in dental x-ray
machine

o may be rotating – affords the ability to

attain greater exposure loads by
providing a larger area for the electron
beam to interact with the target

The X-ray Generator and the X-ray Tube

o should have minimum ratings of 700 to 1000

mA due to short exposure frequency that is
Note: On a single phase, there are 60 distributions of required
energy per second. ,
o control panel should provide the highest
Note: mA is the quantity; kV is the quantity.
possible current in milliamperes at the shortest
❑ The X -ray Tube possible exposure time since this ensures the
best diagnostic quality while minimizing the
o an electrical device used for the generation of radiation exposure to the patient
x-rays
o accomplished by the acceleration of electrons o to provide very repeatable exposures, a small
and then suddenly decelerating them difference in the x-ray tube current & kV in two
o the energy of the x-rays is dependent on the exposures should be prevented if not it will
kinetic energy of the electrons result to an improper mask subtraction
Note: Kinetic energy ay ang dumadaloy na kuryente.
 INTERVENTIONAL RADIOLOGY

Take note of: Reciprocity Law o kung ano ang sakop ng ilaw na ibibigay ng light
diaphragm, iyon lang ang mag-aappear sa tv
Effect: Obscures the visualization of the actual
camera
structures of interest such as opacified vessels.
Remember that there is a very small difference in ❑ The Television Image
contrast between two images.
o this is where the image will appear
❑ The Image Intensifier o the higher the pixel, the better

o this allows the continuous x-ray emission a. The camera should have a low lag to eliminate a
o a high-quality image intensifier is needed for smeared ghost image. This is made possible by a camera
digital applications that erases the image on the input phosphor during the
o there should be a high contrast ratio readout of each frame.
o if a 512x512 pixel matrix is used, high spatial
b. The camera must have an extremely low electronic
resolution is not needed but the input
noise.
phosphor must be thick for high detection
efficiency c. The scan mode should be in the progressive mode
which means that every line is read out in order. It
should also have a slow scan mode. It should be able to
scan 1024x1024 matrix.

❑ The Digital Image Processor – consist of the

following:

➢ central control computer – uses the first image

of the mask & is to display all the consecutive
images as a subtracted image
Note: It is C-shaped for the couch or the bed to be easily When the factors are set in the computer, the
inserted. computer informs the generator when to start and
stop. It sets up the digitizer to convert the entire TV
Note: When the tube and the image receptors /
frame into a digital image. The computer also instructs
intensifiers exchange in position, the image will be
the arithmetic unit what to do with the first digitized
flipped – the reason why doctors don’t want it.
image & where to place the digitized image and to
Note: In C-arm, there is magnification. The image store them in the appropriate box in the memory.
quality, though, is not reduced for we are using medical
➢ analog to digital converter (digitizer) – converts
grade screens. This effect is ideal for ERCP.
the video images into digital form.
❑ The Light Diaphragm
The video signal has a varying voltage which would
o used to control the amount of light from the be low for a dark region of the image & rises to a
image intensifier to the TV camera tube, hence high voltage for a bright image. The digitizer
the light diaphragm must be able to transmit measures the voltage by sending a number to the
the same amount of light that reaches the TV arithmetic unit all the 512 points are measured by
camera both the fluoroscopy & serial portion the digitizer for the voltage.

➢ digital arithmetic unit – converts the

o needed because of the high mA used in the
information the ADC sends into the binary
serial portion; this problem is solved by using number system
different sizes of diaphragm & TV video gains
➢ digital image memory – stores the digitized
number in the memory
o found inside of the tube and employs the same
concept as the x-ray tube collimator
 INTERVENTIONAL RADIOLOGY

Time Interfacing Differencing – a new mask is taken for 5. make the subtraction print (final film) – to obtain a
a new subtraction. Each subtracted image is the subtraction print, the subtraction mask is placed over
difference between images separated by some fixed the angiogram as in step 3. A subtraction print film is
interval. The subtracted images are frequently placed on top of these and exposed for approximately
displayed in a rapid sequence to show the dynamic 35* seconds to light. The subtraction print film is the
motion. processed & an image of only the contrast-filled vessel
is visible.
Note: The computer collects shot by shot then displays
the shots in dynamic motion.

Manual Subtraction Technique

the removal of nonessential or overlying structures,

making the vascular anatomy under study more visible
with enhance patterns done manually

Steps in Production of Subtraction Image

1. scout film – check proper positioning, film size, and

technical factor

2. reversal film – diapositive mask; i-determine if okay

na or may mali pa kay scout film, then proceed na dito
at mag-x-ray na ulit

3. registration – we do this in the dark room with the

help of a blank film na ipapatong sa reversal film then
bubuksan ang ilaw

4. subtraction mask – series of reversal film

5. final film

5 Steps in the Production of Subtraction Image

(Conventional): Explained

1. Select a scout film for the creation of a diapositive

mask.

2. Prepare the diapositive mask or reversal film – the

mask film produced will be the exact copy of the scout
film but with the density’s reversal.

From conventional negative radiograph, a positive

radiograph mask is produced. Black areas are changed
to white & the white areas or attenuated areas of the
scout are changed to black ones.

3. Select one of the contrast-filled angiogram films

(series film) & superimpose that film over the mask – a
process that is called registration.

4. subtraction mask or series reversal film – the

diapositive mask is superimposed over the contrast
filled angiogram film and is exposed for approximately
5 seconds to light. The positive & negative image of the
bones tend to negate each other and only the added
contrast vasculature is visualized.