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| N. Interventional Radiology | ||||||
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CLINICAL/DIAGNOSTIC PROBLEM |
INVESTIGATION |
RECOMMENDATION (GRADE) |
COMMENT |
DOSE |
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| Asymptomatic carotid disease | Endovascular (angioplasty and stents) management | Indicated only in specific circumstances (C) | Critical appraisal of the literature reveals a need for further studies. | III | ||
| Symptomatic carotid disease | Percutaneous balloon angioplasty and stent placement | Indicated only in specific circumstances (B) | The recommended treatment for the majority of patients remains endarterectomy. Potential indications for endovascular treatment includes unsuitability for endarterectomy, status post radiotherapy, surgical restenosis, high lesions or circumstances where treatment is closely audited or part of a structured research in an experienced unit. | III | ||
| Pulmonary embolus | Insertion of IVC filter | Indicated only in specific circumstances (B) | In the presence of known lower limb and/or pelvic venous thrombosis the insertion of an IVC (inferior vena cava) filter is only indicated if there are proven pulmonary emboli despite adequate anticoagulation or when anticoagulation is contraindicated | II | ||
| Pulmonary arteriovenous malformation (AVM) | Pulmonary angiography and embolisation | Specialised investigation (B) | A prerequisite to other diagnostic intervention at the time of treatment by embolisation. | III | ||
| CT | Specialised investigation (B) | May be useful in the diagnosis of pulmonary AVMs. Non-contrast helical study is all that is needed. Some centres recommend this study prior to treatment by embolisation in order to measure feeding vessels and assess anatomy. | III | |||
| CXR | Indicated (B) | CXR is indicated when this diagnosis is suspected and to assess response to treatment. Follow-up assessment is initially performed six-monthly or yearly after embolisation and then five-yearly if no growth. CXR is also indicated as a screening tool in relatives of patients with pulmonary AVMs associated with hereditary haemorrhagic telangiectasia. | I | |||
| MRI brain | Specialised investigation (B) | To look for evidence of previous paradoxical cerebral embolism in patients with pulmonary AVM diagnosis. MRI is also used to look for evidence of cerebral AVMs in patients with associated hereditary haemorrhagic telangiectasia. | 0 | |||
| MRI thorax | Specialised investigation (B) | As an alternative to thoracic CT, to confirm diagnosis of pulmonary AVMs. MRI thorax may be useful for diagnosis, but is not necessary in the majority of patients. | 0 | |||
| NM | Specialised investigation (B) | Perfusion scintigraphy is performed with TC-labelled macroaggregates for measurement of right to left shunt. It is useful for diagnosis and follow-up assessment after treatment. | II | |||
| US | Specialised investigation (C) | Research tool only at present. Doppler US of carotids or cardiac chambers is performed after IV injection of agitated saline or US contrast agent to determine presence of right to left shunt. It is useful for diagnosis. | 0 | |||
| Abdominal aortic aneurysm | Insertion of stent-grafts | Specialised intervention (B) | Endovascular repair of abdominal aortic aneurysms is a procedure that should only be performed in specialist units. | III | ||
| Leg ischaemia (claudication, rest pain with or without tissue loss) with iliac stenotic disease | Primary angioplasty plus selective stenting | Indicated (A) | The decision to place a stent following angioplasty depends on a number of factors, one of which is a residual pressure gradient across the treated area. The exact pressure gradient after PTA (percutaneous transluminal angioplasty) that mandates stent placement is unknown. In general, a mean pressure gradient of 10 mm Hg is considered appropriate | III | ||
| Leg ischaemia (claudication, rest pain with or without tissue loss) with iliac occlusive disease | Iliac stent placement | Indicated (B) | The policy of primary stenting for iliac occlusive disease is accepted. | III | ||
| Leg ischaemia (claudication, rest pain with or without tissue loss) with femoral occlusive disease | Superficial femoral/popliteal artery angioplasty | Indicated (B) | PTA of the superficial femoral and popliteal arteries is effective for restoring patency in the short term, but repeat angioplasty can be performed to avoid the need for surgical bypass. Primary clinical success rates are inferior to those of surgical bypass grafts. | III | ||
| Leg ischaemia (claudication, rest pain with or without tissue loss) with tibioperoneal femoral occlusive disease | Tibioperoneal trunk angioplasty | Indicated (B) | When there is a suitable lesion in the tibioperoneal trunk, angioplasty should be the first-line treatment in patients with critical ischaemia and claudication. | III | ||
| Severe acute GI bleeding from unknown source requiring continuous substitution | Endoscopy/DSA with or without embolisation | Indicated (B) | Stabilising
the patient is a priority. Endoscopy is the first-line intervention.
If endoscopy is negative or unsuccessful, DSA and embolisation follow immediately. However, the patient must be actively bleeding as contrast extravasation is the only diagnostic sin to locate a source. Unsuccessful embolisation indicates surgery. |
0/III | ||
| Variceal haemorrhage | TIPS | Indicated only in specific circumstances (A) | Endoscopic therapy should be the first-line treatment for bleeding varices, with TIPS (transjugular intrahepatic portocaval shunt) reserved for treatment failures. Surgical portosystemic shunting is more durable and may be preferred in medically fit patients. | III | ||
| Ascites due to portal hypertension | TIPS | Indicated only in specific circumstances (B) | TIPS is of limited efficacy and is associated with substantial mortality, particularly in Child's grade C liver disease and/or renal impairment | III | ||
| Acute massive lower GI haemorrhage | DSA and/or embolisation | Indicated (B) | DSA and embolisation is safe and effective when GI bleeding is life-threatening. | III | ||
| Chronic or recurrent upper GI haemorrhage | DSA and/or embolisation | Specialised intervention (C) | Only undertaken after appropriate imaging. Recurrent blood loss can be investigated with DSA and/or NM (red cell) study. | III | ||
| Chronic mesenteric ischaemia | Superior mesenteric artery PTA/superior mesenteric artery stenting | Indicated (B) | In carefully selected patients mesenteric artery PTA can be performed relatively safely with good technical and clinical results. Superior mesenteric artery stenting can improve the result of angioplasty and may become the therapy of choice in ostial superior mesenteric artery stenosis. | III/III | ||
| Subphrenic abscess | US-/CT- guided percutaneous drainage of subphrenic abscess | Indicated (C) | US is the best technique for draining subphrenic abscesses as it allows an angled approach and real-time imaging. CT may also be helpful in that it may provide a more detailed road map including accurate localisation of pleural space. | 0/III | ||
| Pelvic abscess | CT-/US- guided catheter drainage | Indicated (B) | Percutaneous-transperineal, transsciatic, transrectal, and transvaginal routes are all effective in the treatment of pelvic abscess. The presence of an enteric fistula is a risk factor for failure. | III/0 | ||
| High biliary obstruction (intrahepatic ducts or upper half of extrahepatic bile duct) | Percutaneous transhepatic cholangiography | Indicated (B) | Choice of endoscopic or transhepatic route for cholangiography may depend on local expertise. Percutaneous drainage is not recommended as a long-term option due to catheter problems such as peri-drain leak, drain displacement and cholangitis. For surgical reconstruction percutaneous transhepatic cholangiography may be more valuable than endoscopic retrograde cholangiography since it defines the anatomy of the proximal biliary tree. | III | ||
| Low biliary obstruction (Lower half of extrahepatic bile duct or pancreatic duct) | Percutaneous transhepatic cholangiography | Indicated (B) | Preference for transhepatic or endoscopic retrograde cholangiography may depend on local expertise. | III | ||
| Actual or suspected acute calculous or acalculous cholecystitis | Percutaneous transhepatic or transperitoneal cholecystostomy | Indicated (B) | Percutaneous transhepatic or transperitoneal cholecystostomy is appropriate in the diagnosis and management of actual or suspected acute calculous or acalculous cholecystitis in high-risk patients. | III | ||
| Hypertension due to fibromuscular dysplasia | Renal PTA with or without stent | Indicated (B) | Renal PTA in a specialist centre is indicated | III | ||
| Hypertension due to atherosclerotic renal artery stenosis | Renal PTA with or without stent | Indicated only in specific circumstances (A) | Hypertension due to atherosclerotic renal artery stenosis should be treated by medical therapy. Renal PTA/stenting may be beneficial in selected patients with uncontrollable hypertension | III | ||
| Renal failure due to atherosclerotic renal artery stenosis | Renal PTA with or without stent | Indicated only in specific circumstances (B) | Indications for renal PTA/stenting are not established. These procedures should only be performed after careful patient selection in specialist centres. | III | ||
| Flash pulmonary oedema due to atherosclerotic renal artery stenosis | Renal PTA with or without stent | Indicated (B) | Renal PTA/stenting should be considered in patients with recurrent pulmonary oedema with tight bilateral renal artery stenosis or stenosis in a single kidney. | III | ||
| Renal calculi | Percutaneous nephrolithotomy | Indicated (C) | Percutaneous nephrolithotomy is generally accepted as the first-line treatment for renal stones 3 cm or more in maximum diameter, as well as with certain anatomical abnormalities such as calyceal diverticula and rotated/ectopic kidneys, and in the morbidly obese patients, when other treatment modalities have failed | III | ||
| Varicocele | Embolisation of varicocele | Indicated (A) | Embolisation is effective in the management of varicocele, either for subfertility or for symptoms, and is associated with fewer complications than surgery. | III | ||
| Abdominal trauma with acute GI bleeding with or without retroperitoneal or intraperitoneal haemorrhage | DSA/embolisation | Specialised intervention (C) | Intervention when the patient is stable. The patient must be actively bleeding as contrast extravasation is essential for the source of haemorrhage to be located by DSA. Embolisation or surgery may follow as appropriate. | III | ||
| Embolisation for uncontrolled haemorrhage after pelvic fracture | Pelvic embolisation | Indicated (A) | Patients with pelvic fractures who remain haemodynamically unstable after initial resuscitation should undergo diagnostic pelvic angiography with embolisation if a source of arterial bleeding is identified. | III | ||
| Pulmonary mass: diagnosis | Fluoroscopic lung biopsy | Specialised intervention (B) | Fluoroscopic lung biopsy in appropriately selected cases and performed by experienced operators has a low complication rate and high diagnostic yield for pulmonary malignancy. | III | ||
| CT-guided lung biopsy | Specialised intervention (B) | CT-guided lung biopsy is an accurate means of obtaining a diagnosis of malignancy or benign disease (if a cutting needle is used) in patients with large or small pulmonary nodules. | III | |||
| US-guided lung biopsy | Specialised intervention (B) | For appropriately selected patients with pulmonary lesions abutting the chest wall, US-guided biopsy is a safe and accurate method of obtaining a tissue diagnosis. | 0 | |||
| Mediastinal mass (non-vascular | CT-guided biopsy | Specialised intervention (B) | CT guidance can be used to aid biosy of anterior, middle and posterior mediastinal masses. | III | ||
| US-guided biopsy | Specialised intervention (B) | The majority of anterior mediastinal masses can be safely and accurately biopsied using US guidance. Alternative biopsy routes to the parasternal approach such as a supraclavicular approach may be helpful. | 0 | |||
| Vena caval obstruction | SVC/IVC stent placement | Specialised intervention (B) | Patients with malignant SVC/IVC obstruction are often fail and have a short life expectancy. Their symptoms are distressing and are usually incompletely relieved by radiotherapy. SVC/IVC stenting is a simple palliative procedure performed under local anaesthesia. Following stenting, most patients will remain asymptomatic. Symptomatic recurrence occurs in about 10% of patients and is usually amenable to repeat treatment. Early referral is preferable as extensive venous thrombosis complicates treatment. Stenting should be the first-line treatment of malignant SVC/IVC obstruction caused by cancers that do not respond quickly to chemotherapy or radiotherapy. Alternatives to stenting (angioplasty and surgery) should be considered in patients with benign strictures and those with long life expectancy. | III | ||
| Percutaneous gastrostomy required for enteral nutrition | Specialised intervention (B) | There is little to choose between percutaneous and endoscopic placement of gastrostomy catheters. The technique of choice may be dependant on local expertise available | III | |||
| Focal liver lesion(s) requiring biopsy | CT-/US-guided biopsy | Indicated (B) | The guideline assumes normal coagulation indices. Image guidance is dependant on local expertise | III/0 | ||
| Unresectable liver tumours | Radiofrequency ablation | Specialised intervention (B) | Radiofrequency ablation should be used in patients with a small number of accessible liver tumours unsuitable for hepatic resection. | III | ||
| Primary hepatoma and liver metastases | Radiofrequency ablation/hepatic chemo-embolisation | Indicated (B) | Radiofrequency ablation is indicated for primary hepatoma and liver metastases. For the vast majority of liver metastases it is more effective than chemoembolisation. Hepatic chemoembolisation has a significant antitumoral effect but this is offset by liver decompensation secondary to embolisation of non-tumour-bearing liver. Selective chemoembolisation should minimise the side-effects of this treatment. Chemoembolisation has been used for palliation in neuroendocrine tumours and metastatic sarcoma | III/III | ||
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