Interventional Radiology in Palliative Care (Medical Radiology)

Foreword
Preface
Contents
Part I: Introduction and Nutrition
	Introduction to Palliative Care
		1	 Introduction
		2	 What Is Palliative Care?
		3	 Why Is This Important for Interventional Radiologists?
		4	 The History of Palliative Care
		5	 The “Upstreaming” of Palliative Care
		6	 Specialist Palliative Care
		7	 Awareness of Services
		8	 The Place of Interventional Radiology in Palliative Care
		9	 Practical Considerations with Interventional Radiological Palliative Procedures
		10	 Summary
		References
	Introduction to IR
		References
	Clinical Applications of Outcome Measurement
		1	 Introduction
		2	 Why Do We Need Outcome Measures?
		3	 What Outcome Measures Should We Use?
			3.1	 Patient-Reported Outcome Measures (PROMs)
			3.2	 Other Patient-Centric Outcomes
			3.3	 Burdens on the Caregiver
			3.4	 Cost Savings and Facilitating Transitions of Care
		4	 Choosing the Right Measures
			4.1	 Requirements for Good Outcome Measures in Clinical Care (Greenhalgh et al. 1998)
		5	 Barriers to Using Outcome Measures in Clinical Care
		6	 Getting Started with Outcome Measurement
		References
	Ethics, Consent, and Communication Challenges
		1	 Introduction
		2	 Medical Futility at the End of Life
		3	 Shared Decision-Making at the End of Life
		4	 Decision-Making Capacity
		5	 Informed Consent
		References
	Intravenous Access Solutions
		1	 Introduction
		2	 Peripherally Inserted Central Catheters (PICCs) and Non-tunnelled Central Venous Catheters
			2.1	 Indications and Contraindications
			2.2	 Patient Preparation
			2.3	 Technique
				2.3.1	 Peripherally Inserted Central Catheter
				2.3.2	 Non-tunnelled Central Catheters
				2.3.3	 Femoral Vein
				2.3.4	 Subclavian Vein
		3	 Tunnelled Central Venous Catheters (TCVC)
			3.1	 Indications
			3.2	 Contraindications
			3.3	 Patient Preparation
			3.4	 Technique
		4	 Subcutaneous Ports
			4.1	 Indications
			4.2	 Contraindications
			4.3	 Technique
		5	 Complications
		6	 Post-procedure Care
		References
	Feeding Solutions
		1	 Introduction
		2	 Ethical Issues in Nutrition in Palliative Care
		3	 Effects of Nutritional Support
			3.1	 Pathophysiological Changes
			3.2	 Nutritional Support
			3.3	 Artificial Nutrition
		4	 Interventional Radiology and Nutrition
			4.1	 Enteral Feeding
				4.1.1	 Nasogastric Tube Insertion
				4.1.2	 Nasojejunal Tube Insertion
			4.2	 Modifications of Feeding Tubes
				4.2.1	 Percutaneous Radiological Gastrostomy (PRG)
					4.2.1.1 Pull Type
					4.2.1.2 Push Type
					4.2.1.3 Results and Complications
				4.2.2	 Primary Radiological Jejunostomy
			4.3	 Aiding Oral Feeds by Radiological Stent Placement
				4.3.1	 Oesophageal Stent
				4.3.2	 Gastro-duodenal Stent
			4.4	 Parenteral Nutrition
				4.4.1	 Catheter Types and Recommendations
				4.4.2	 Complications
				4.4.3	 Parenteral Hydration
		5	 Conclusion
		References
Part II: Musculoskeletal Pain Relief Solutions
	Imaging-Guided Palliative Procedures: Tendon and Bursa Injection
		1	 Introduction
		2	 Image-Guided Tendon and Bursal Injection Basics
		3	 Chemotherapeutic Causes of Arthralgia, Tendinopathy, Synovitis, and Bursitis
		4	 Radiotherapy Causes of Myositis, Tendonitis, and Bursitis
		5	 Systemic Steroid Use in Palliation and Its Effects on Tendons
		6	 Local Steroid Injections to Reduce Focal Inflammation
		7	 Calcific Tendonitis Intervention
			7.1	 Rotator Cuff
			7.2	 Gluteal Musculature
			7.3	 Longus Colli
			7.4	 Less Common Sites of Calcific Tendinopathy
		8	 Bursal Intervention
		9	 Tendon Intervention
		10	 Gout and Crystal Arthropathies
		11	 Summary
		References
	Cement Consolidation: Vertebral Augmentation and Cementoplasty
		1	 Introduction
		2	 Indications
		3	 Materials
		4	 General Technical Considerations
		5	 Vertebral Augmentation
		6	 Cementoplasty: Outside of the Spine
		7	 Complications
		8	 Conclusion
		References
	Palliative Bone Tumors Thermal Ablation
		1	 Introduction
		2	 Palliative Bone Ablation in Cancer Patients
		3	 Ablative Techniques
		4	 Protective Measures
			4.1	 Techniques Achieving Physical Displacement
			4.2	 Morphological/Functional Monitoring
		5	 Results
		6	 Advantages of Ablations
		7	 Conclusions
		References
Part III: Neurological Pain Relief Solutions
	Epidural Steroid Injections
		1	 Introduction
		2	 Anatomy of the Epidural Space
		3	 Cervical Epidural Injections
			3.1	 Indications
			3.2	 Contraindications
			3.3	 Cervical Epidural Transforaminal Epidural
				3.3.1	 Injection Technique
			3.4	 Cervical Interlaminar Epidural
				3.4.1	 Injection Technique
				3.4.2	 Loss of Resistance Technique
				3.4.3	 Hanging Drop Technique
			3.5	 Complications
				3.5.1	 Drug Related
				3.5.2	 Procedure Related
		4	 Lumbar Epidural Injections
			4.1	 Indications
			4.2	 Contraindications
			4.3	 Lumbar Transforaminal Epidural
				4.3.1	 Injection Technique
			4.4	 Lumbar Interlaminar Epidural
				4.4.1	 Injection Technique
			4.5	 Complications
				4.5.1	 Drug Related
				4.5.2	 Procedure Related
		5	 Caudal Epidural Injection
			5.1	 Indications
			5.2	 Contraindications
			5.3	 Caudal Epidural Injection Technique
			5.4	 Complications
				5.4.1	 Drug Related
				5.4.2	 Procedure Related
		6	 Conclusion
		References
	Spinal Facet Injections for Palliative Pain Management
		1	 Introduction
		2	 Anatomy and Function of the Facet Joints
		3	 Disease Processes Affecting the Facet Joints
			3.1	 Degenerative
			3.2	 Neoplastic
			3.3	 Rheumatologic
			3.4	 Infectious
			3.5	 Traumatic
		4	 Treatment Strategies for Facet Pain
			4.1	 Conservative and Pharmacologic Therapies
			4.2	 Median Branch Blocks
			4.3	 Radiofrequency Ablation
			4.4	 Facet Injections and Aspirations
			4.5	 Surgical Techniques
		5	 Effectiveness of Facet Injections
		6	 Complications of Facet Injections
		7	 Conclusion
		References
	Spinal Nerve Root Blocks
		1	 Introduction
		2	 Indications and Patient Selection
		3	 Contraindications and Limitations
		4	 Techniques
			4.1	 Modalities and Equipment
				4.1.1	 Needles
				4.1.2	 CT vs. Fluoroscopy Guided
				4.1.3	 Planning
			4.2	 Medications
			4.3	 Cervical Nerve Root Blocks
			4.4	 Thoracic Nerve Root Blocks
			4.5	 Lumbar and Sacral Nerve Root Blocks
			4.6	 Spinal Epidural Injections
		5	 Post-procedure Care and Follow-Up
		6	 Conclusion
		References
	Nerve Blocks (Non-spinal)
		1	 Introduction
		2	 Indications
		3	 Contraindications
		4	 Therapeutic Options
			4.1	 Local Anesthetics
			4.2	 Thermal Neurolysis
			4.3	 Pulsed Radiofrequency (Neural Modulation)
			4.4	 Chemical Neurolysis
		5	 Techniques for Common Peripheral Nerve Blocks
			5.1	 Head and Neck
			5.2	 Trunk
			5.3	 Upper Extremity
			5.4	 Pelvis and Lower Extremity
		6	 Associative Therapies
		7	 Conclusion
		References
	Autonomic Blocks
		1	 Introduction
		2	 Functional Anatomy of Visceral Autonomic Nervous System
		3	 Celiac Plexus Neurolysis (CPN)
			3.1	 Indications
			3.2	 Contraindications
			3.3	 Pre-procedural Evaluation
			3.4	 Technique
				3.4.1	 Imaging Guidance and Patient Positioning
				3.4.2	 Site of Neurolytic Injection
				3.4.3	 Various Approaches
					3.4.3.1 Paravertebral Posterior Approach
					3.4.3.2 Anterior Approach
					3.4.3.3 Other Approaches
			3.5	 Superior Hypogastric Plexus Neurolysis (SHPN)
				3.5.1	 Functional Anatomy
				3.5.2	 Technique
				3.5.3	 Ganglion Impar Neurolysis (GIN)
				3.5.4	 Post-procedure Care
				3.5.5	 Complications
				3.5.6	 Clinical Efficacy
			3.6	 Conclusion
		References
Part IV: Tumour Debulking Solutions
	Endovascular Embolisation Techniques
		1	 Introduction
		2	 Indications
		3	 Contraindications
		4	 Techniques
			4.1	 Access
			4.2	 Vascular Supply
			4.3	 Cannulisation of Target Vessels
			4.4	 Embolic Agents
			4.5	 Phasing of Embolisation
			4.6	 Safety Aspects
		5	 Associative Therapies
		6	 Follow-Up
		7	 Conclusion
		References
	Tumour Ablations
		1	 Introduction
		2	 Techniques of Ablation
			2.1	 Radiofrequency Ablation (Pereira et al. 2004)
			2.2	 Microwave Ablation (Simon et al. 2005; Brace 2009)
			2.3	 Cryo-ablation (Rose and Morris 2015; Erinjeri 2013)
			2.4	 Other Ablative Therapies
				2.4.1	 High-Intensity Focused Ultrasound (HIFU)
				2.4.2	 Chemical Ablation (Garnon et al. 2013)
		3	 Patient Preparation
		4	 Anaesthesia for Ablation (Fox and Harvey 2005)
		5	 Various Regions
			5.1	 Chest
				5.1.1	 Procedure
			5.2	 Liver
			5.3	 Adrenal
			5.4	 Kidneys
			5.5	 Prostate
			5.6	 Primary Bone and Soft Tissue Tumours
			5.7	 Other Regions
		6	 Conclusion
		References
Part V: Bleeding Solutions
	Bleeding Solutions in the Head and Neck
		1	 Introduction
			1.1	 Pre-procedural Consideration
		2	 Management of Acute Haemorrhage
			2.1	 Epistaxis
				2.1.1	 Tumour-Induced Epistaxis
				2.1.2	 Post-treatment Epistaxis
			2.2	 Carotid Blowout
				2.2.1	 Role of Endovascular Therapy in Carotid Blowout Syndrome (CBS)
				2.2.2	 Permanent Balloon Occlusion (PBO)
				2.2.3	 Selective Embolization
				2.2.4	 Endovascular Stent Placement
		3	 Palliative Embolization of Tumours
		4	 Limitations of Endovascular Treatment
		5	 Post-procedural Consideration
		References
	Gastro-intestinal Bleed
		1	 Introduction
		2	 Clinical Assessment, Resuscitation, and Initial Management (Ramaswamy et al. 2008)
		3	 Role Computed Tomographic Angiography (CTA) (Ramaswamy et al. 2014; Wortman et al. 2017)
		4	 Role of Scintigraphy (Ramaswamy et al. 2014)
		5	 Embolization Agents (Vaidya et al. 2008; Kondo 2009)
			5.1	 Particles
				5.1.1	 Polyvinyl Alcohol (PVA) Foam
				5.1.2	 Other Particle Agents
			5.2	 Liquid Agents
				5.2.1	 Glue/NBCA
				5.2.2	 Ethylene Vinyl Alcohol/Dimethyl Sulfoxide (Onyx)
				5.2.3	 Sclerosants
			5.3	 Coils, Plugs, and Occlusion Devices
				5.3.1	 Coils
		6	 Causes of GI Bleed
			6.1	 Non-variceal GI Bleed
				6.1.1	 Upper GI Bleed (Lee and Laberge 2004)
				6.1.2	 Lower GI Bleed (Lee and Laberge 2004):
				6.1.3	 Angiography and Embolization (Non-variceal Bleed)
			6.2	 Variceal Bleed
				6.2.1	 TIPSS
				6.2.2	 BRTO
		7	 Conclusion
		References
	Bleeding Solutions for Genitourinary Tract
		1	 Introduction
		2	 Disease Presentations and Adjunctive Therapy
			2.1	 Haematuria
				2.1.1	 Advanced Bladder Cancer
				2.1.2	 Prostatic Bleeding
			2.2	 Vaginal Bleeding
		3	 Interventional Radiology Procedures
			3.1	 Transcatheter Arterial Embolotherapy
				3.1.1	 General Principles
				3.1.2	 Internal Iliac (Hypogastric) Artery Embolization
				3.1.3	 Prostatic Artery Embolization (PAE)
				3.1.4	 Uterine Artery Embolization
				3.1.5	 Renal Artery Embolization
			3.2	 Bilateral Ureteric Embolization
			3.3	 Percutaneous Thermal Ablation
			3.4	 Potential Complications and Limitations
		4	 Conclusion
		References
	Bleeding Solutions in Lung
		1	 Introduction
		2	 Etiology
		3	 Anatomical Considerations
		4	 Solutions
			4.1	 Diagnostic Solutions
			4.2	 Treatment Solutions
		5	 Embolization
			5.1	 Bronchial Artery Embolization
			5.2	 Non-bronchial Systemic Artery Embolization
			5.3	 Pulmonary Artery Embolization
		6	 Stenting
			6.1	 Pulmonary Artery Stenting
			6.2	 Tracheo-Bronchial Tree Stenting
		7	 Ablation
		8	 Conclusion
		References
	Bleeding Solutions in Hepatobiliary Pancreatic Systems
		1	 Introduction
		2	 Indications
		3	 Contraindications
		4	 Anatomy
		5	 Technique
			5.1	 Preparation
			5.2	 Access
			5.3	 Catheter Choice and Angiography
			5.4	 Embolic Agents
				5.4.1	 Coils
				5.4.2	 Particulate Embolic Agents
				5.4.3	 Liquid Embolic Agents
				5.4.4	 Vascular Plugs
			5.5	 Embolization Techniques
		6	 Complications
		7	 Conclusion
		References
	Bleeding Solutions for Fungating Masses
		1	 Introduction
		2	 Etiology
		3	 Clinical Presentation
		4	 Management of Bleeding from Fungating Masses
			4.1	 Local Wound Care
			4.2	 Systemic Treatment
			4.3	 Interventional Radiology
				4.3.1	 Embolisation
				4.3.2	 Stent Graft Insertion
				4.3.3	 Transarterial Chemo Embolisation (TACE)
				4.3.4	 Image-Guided Tumour Ablation
			4.4	 Surgery
			4.5	 Radiation
		5	 Conclusion
		References
Part VI: Obstruction Solutions
	Malignant Bile Duct Obstruction (MBDO): Obstruction Solutions for Liver and Gallbladder
		1	 Introduction
		2	 Indications
		3	 Contraindications
		4	 Patient Preparation
		5	 Relevant Anatomy and Variants of Biliary Tree
			5.1	 Relevant Anatomy
			5.2	 Relevant Variants of Bile Ducts
		6	 Evaluation of Imaging Pertinent to Technique
			6.1	 Determining the Level of Obstruction
			6.2	 Bismuth Classification and Presence of Isolation
			6.3	 Anatomical Variants of Bile Ducts
			6.4	 Adequate Functional Liver Parenchyma
			6.5	 Presence or absence of Portal Vein Thrombosis (PVT)
		7	 Equipment
		8	 Techniques
			8.1	 Biliary Access and Percutaneous Transhepatic Cholangiography (PTC)
			8.2	 Percutaneous Transhepatic Biliary Drainage (PTBD)
			8.3	 Percutaneous Biliary Stenting
				8.3.1	 Plastic Versus Metallic Stents
				8.3.2	 Covered Versus Bare (Uncovered) Metallic Stents
				8.3.3	 Drug Eluting Stents and Intraductal Ablation
			8.4	 Recurrent Occlusion After Stent Placement
		9	 Post-procedural Care
		10	 Outcomes
		11	 Complications
		12	 Conclusion
		References
	Obstruction Solutions for Kidneys and Urinary Bladder
		1	 Introduction
		2	 Percutaneous Nephrostomy
		3	 Anatomy
		4	 Patient Preparation
		5	 Technique
		6	 Antegrade Ureteric Stenting
		7	 Technique
		8	 Complications of Percutaneous Nephrostomy
		9	 Image-Guided Suprapubic Catheter Placement
		10	 Technique
		11	 Complications
		12	 Conclusion
		References
	Role of IR in Large Bowel Obstruction
		1	 Introduction
		2	 Patient Selection
		3	 Technique
			3.1	 Preparation
			3.2	 Patient Positioning
			3.3	 Disposable Equipment
			3.4	 Procedure
		4	 Discussion
			4.1	 Stenting Versus Surgery
			4.2	 Choice of Endoscopic or Fluoroscopic Technique
			4.3	 Choice of Stent Design
			4.4	 Use of Stenting as a Bridge to Surgery
			4.5	 Author’s Own Results and an Interesting Complication
		5	 Conclusion
		References
Part VII: Drainages
	Effusions
		1	 Introduction
		2	 Indications
		3	 Imaging
		4	 Contraindications
		5	 Techniques
			5.1	 Thoracentesis
			5.2	 Pleurodesis
			5.3	 Indwelling Pleural Catheters
			5.4	 Pleuroperitoneal Shunts
		6	 Complications
		7	 Follow-Up
		8	 Comparison of Techniques
		9	 Conclusion
		References
	Ascites and Fluid Collections
		1	 Introduction
		2	 Indications
		3	 Contraindications
		4	 Techniques
			4.1	 Paracentesis
			4.2	 Indwelling Peritoneal Catheters
			4.3	 Peritoneovenous Shunts
			4.4	 TIPSS
		5	 Complications
		6	 Follow-Up
		7	 Comparison of Techniques
		8	 Conclusion
		References
	Abscesses
		1	 Introduction
		2	 Preprocedural Planning, Preparation, and Contraindications
			2.1	 Planning
			2.2	 Preprocedural Preparation
			2.3	 Contraindications
		3	 Laboratory Evaluation of Coagulation Status, Anticoagulation Management and Antibiotic Consideration
			3.1	 Evaluation of Coagulation Status
			3.2	 Management of Anticoagulation
			3.3	 Consideration of Antibiotic Therapy
		4	 Selection of Imaging Guidance Modality
			4.1	 Ultrasonography (US)
				4.1.1	 Techniques
			4.2	 Computed Tomography (CT)
				4.2.1	 Techniques
		5	 Procedure Preparation and Aspiration
		6	 Catheter Placement
			6.1	 Catheter Insertion and Placement Techniques
				6.1.1	 Trocar Technique
				6.1.2	 Seldinger Technique
			6.2	 Selection of Needle Systems and Catheters
		7	 Catheter Fixation and Management
		8	 Special Approaches for Difficult Abscess Locations
			8.1	 Deep Pelvis
				8.1.1	 US-Guided Transvaginal and Transrectal Approaches
				8.1.2	 CT-Guided Transgluteal Approach
			8.2	 Upper Abdomen
				8.2.1	 Subphrenic Regions (Subcostal and Intercostal Approaches)
			8.3	 Epigastrium, Pancreatic and Peripancreatic Abscesses
				8.3.1	 Gastrocolic Approach
				8.3.2	 Left Anterior Pararenal Space Approach
				8.3.3	 Gastrosplenic Approach
				8.3.4	 Transhepatic Approach
			8.4	 Visceral Abscesses (Include Hepatic, Splenic, and Renal Abscesses)
		9	 Post-procedure Management
			9.1	 Adjunctive Thrombolytic Therapy
		10	 Complications
		11	 Conclusion
		References
Part VIII: Miscellaneous
	Treatment of Fistulas
		1	 Introduction
		2	 Abscess–Fistula Complex
		3	 Fistula of the Gastrointestinal Tract
			3.1	 Enterocutaneous Fistula
			3.2	 Esophagorespiratory Fistula
			3.3	 Enterovesical Fistula
		4	 Fistula of the Genitourinary Tract
			4.1	 Fistulas in Gynecologic Malignancies
			4.2	 Ureteroenteric Fistula
		5	 Fistula Related to Interventional Oncology Procedures
			5.1	 Bronchopleural Fistula
			5.2	 Enteric and Biliary Fistulas
		6	 Conclusion
		References
	Intrathecal Pain Pumps: Placement and Management
		1	 Introduction and Background for Intrathecal Pumps Used for Pain and Spasticity
			1.1	 Intrathecal Drug Delivery for Pain
			1.2	 Intrathecal Drug Delivery for Spasticity
		2	 The Components of Intrathecal Drug Delivery
			2.1	 SynchroMed II Intrathecal Pump
			2.2	 Ascenda Catheter
			2.3	 Catheter Insertion Kit
			2.4	 SynchroMed II Clinician Programmer and Patient Therapy Manager
			2.5	 Supplies for Intrathecal Pump Implantation
		3	 Intrathecal Implant Technique
			3.1	 Targeted Drug Delivery Trialing and Preoperative Planning Considerations
				3.1.1	 ITB Trialing
				3.1.2	 Pain Pump Trialing
					3.1.2.1 Trialing and the Type of Pain
					3.1.2.2 Trial Dosing and Method
					3.1.2.3 Whether or Not to Trial
					3.1.2.4 Dosing and Medication Selection
					3.1.2.5 Side Effects
					3.1.2.6 Trial Environment
					3.1.2.7 Comorbidities and Medication Interaction
					3.1.2.8 Complications of Trialing
					3.1.2.9 Catheter Dislodgement
					3.1.2.10 Psychological Fitness for Trialing
			3.2	 Appropriate Patient Positioning
			3.3	 Key Steps in Pump Implant Procedure
			3.4	 Catheter Placement
			3.5	 Pump Pocket Preparation
			3.6	 Catheter Tunneling
			3.7	 Catheter and Pump Connection
			3.8	 Closure of Incisions
			3.9	 Post-Op Instructions
		4	 Intrathecal Drug Delivery—Pump Management
			4.1	 Management of Intrathecal Pain Pumps
				4.1.1	 Patient Selection for IT Therapy
				4.1.2	 IT Therapy in Different Pain States
				4.1.3	 Starting Doses and Bolus Dosing
				4.1.4	 Compounding of Intrathecal Drugs
				4.1.5	 Intrathecal Medication Combinations
				4.1.6	 Training and Educational Qualifications for Physicians Implanting and Managing Intrathecal Medication Therapy
				4.1.7	 Continuation of Effective Intrathecal Opioid Therapy
				4.1.8	 Opioid Tolerance and Its Effect on IT Opioid Therapy
				4.1.9	 IT and Systemic Medication Strategies
				4.1.10	 Sustainability of IT Opioid Therapy
			4.2	 Management of Intrathecal Baclofen Pumps
		5	 Intrathecal Pump and Catheter Troubleshooting
			5.1	 Catheter and Rotor Study
		6	 Conclusion
		References