INTERVENT RADIOL: SURVIVAL GUIDE 3E

Description

Interventional Radiology: A Survival Guide provides radiology and vascular surgery trainees and practitioners with clear step by step guidance on the most commonly performed diagnostic and therapeutic procedures. The text is broken up into three sections: general principles, vascular intervention and non-vascular intervention. Each chapter includes a brief paragraph outlining basic principles and theory, advice about choosing the correct catheter and device, practical guidance on how best to perform a procedure and highlights possible complications as well as tips on how to solve commonly encountered problems. Almost 300 illustrations make complex information easy to understand and apply. Cover Frontmatter Copyright Preface Acknowledgements Abbreviations Preparing for successful and safe procedures Patient preparation Evaluation Screening tests Information Informed consent Consent issues Special circumstances Emergencies Competence to make decisions Inability to comprehend Fluctuating capacity Children Managing high-risk patients The patient’s general condition American Society of Anesthesiologists (ASA) status classification system The patient has a history of anaphylactic reaction to intravascular contrast The patient is anticoagulated or has a severe bleeding diathesis Diabetes Non-insulin-dependent diabetic patients Insulin-dependent diabetic patients Renal impairment Hypertension Heart failure Gastric contents Demented, anxious and agitated patients Suggestions for further reading Patient information sheets Screening tests High-risk patients Interventional pause Advance planning On the day: staff, equipment and room preparation Before starting Introductions Explanations Post-procedure care Suggestions for further reading Contrast Intravascular X-ray contrast agents Iodinated contrast media Contrast reactions with iodinated contrast media Direct effects Renal Cardiac Haematological Neurological Idiosyncratic reactions Assessing the risk Reducing the risk Treatment of contrast reactions Minor reactions Intermediate–severe reactions MRI contrast agents Gadolinium Nephrogenic systemic fibrosis (NSF) Negative contrast agents – CO2 Equipment Injecting CO2 Filling syringes with CO2 Troubleshooting Suggestions for further reading Alternatives to iodinated contrast media Sedation Conscious sedation Deep sedation and anaesthesia To sedate or not to sedate, that is the question Sedation guidelines Patient selection Care and monitoring of sedated patients Care Monitoring Pulse oximetry and respiratory rate ECG Pulse and blood pressure Aftercare Suggestions for further reading Pain control and analgesia If a procedure is predicted to be painful If a patient experiences unexpected pain during or after a procedure If a procedure is likely to have painful consequences Some typical regimens Non-steroidal anti-inflammatory drugs Opiate analgesics Patient-controlled analgesia Suggestions for further reading Drugs used in interventional radiology Antidotes Benzodiazepine reversal Flumazenil (Anexate) Opiate reversal Naloxone Abnormal clotting and anticoagulation reversal Correcting coagulopathy – when and how Abnormal INR Vitamin K1 Reversal of warfarin Rapid reversal of warfarin Fresh frozen plasma (FFP) Dried prothrombin complex (Beriplex) Reversal of heparin Protamine sulphate Reversal of low molecular weight heparin Prevention of crises Antihypertensive agents Nifedipine Labetalol Carcinoid crisis Octreotide Anaesthetics, analgesics and sedatives Local anaesthetics Lidocaine hydrochloride (Xylocaine) Prilocaine hydrochloride Bupivacaine hydrochloride (Marcain) Analgesics (see Chapter 5, Pain control and analgesia) Paracetamol (acetaminophen) Diclofenac Opiates Morphine Fentanyl Sedatives (see Chapter 4, Sedation) Midazolam Diazepam Vasoactive drugs Vasodilators Tolazoline Papaverine Glyceryl trinitrate Vasoconstrictors Drugs affecting coagulation Heparins Unfractionated heparin Low molecular weight heparin Platelets Antiplatelet agents Aspirin Dipyridamole Clopidogrel Glycoprotein IIb/IIIa inhibitors (e.g. abciximab) Thrombolytic agents Recombinant tissue plasminogen activator Urokinase Streptokinase Drugs promoting blood clotting Tranexamic acid Thrombin Drugs reducing peristalsis Hyoscine butylbromide (Buscopan) Glucagon Antibiotics Antiemetics Metoclopramide Prochlorperazine (Stemetil) Cyclizine (Valoid) Ondansetron (Zofran) Drugs to prevent and treat contrast reactions Chlorphenamine (Piriton) Hydrocortisone sodium succinate Prednisolone Adrenaline (epinephrine) Atropine Cimetidine Antiarrhythmics Adenosine Glycopyrronium bromide (glycopyrrolate, Robinul) Suggestions for further reading Drugs used in the imaging department Non-invasive vascular imaging Vascular ultrasound Principal uses Ultrasound guided intervention Assessment of abdominal aortic aneurysm (AAA) Follow-up of peripheral vascular intervention Assessment of patients with renal arterial disease Assessment of patients with carotid artery disease Basic principles Probe Settings What to look for Peripheral vascular doppler Iliac vascular ultrasound Femoropopliteal segment Calf vessels Common pitfalls in peripheral vascular ultrasound Magnetic resonance angiography CE-MRA keys to success Areas in which CE-MRA is accepted Computed tomography angiography (CTA) CTA: keys to success Suggestions for further reading Angiography – getting the picture Fluoroscopy Fluoroscopy or screening Last image hold Guide to good fluoroscopy Catheter guidance Roadmap (non-subtracted fluoroscopy) Roadmap (subtracted fluoroscopy) Digital subtraction angiography: basic principles Digital subtraction angiography techniques Multi-position DSA (MPDSA) Stepping table DSA Bolus-chasing DSA Rotational angiography and angiographic CT Dose reduction Hard copy/archival Pixel shifting Masking Pump injectors Equipment for angiography Size Guidewires Basic properties of guidewires Hydrophilic guidewires Length Wire tip Stiffness Stiffness ratings of guidewires Diameters Non-steerable guidewires J guidewire Bentson wire Straight wire Other ‘heavy-duty’ guidewires, e.g. Rosen wire Amplatz super-stiff wire Meier wire/Lunderquist wire Platinum plus Steerable guidewires Terumo angled hydrophilic wire V18 Catheters Essential catheters Non-selective catheters Pigtail catheter Straight catheter Flow rates for non-selective catheters Selective catheters Endhole vs sideholes Top five selective catheters Cobra Sidewinder (a.k.a Simmons) Berenstein Renal double curve (RDC) Headhunter Co-axial systems Guide-catheters Guide-catheters vs introducer guides (long sheaths) Microcatheters Vascular sheaths Other essential equipment Vascular access Mini access set Haemostatic devices – taps Haemostatic valves Tuohy–Borst adaptors Connectors High-pressure connectors Low-pressure connectors Pin-vice Vascular snares Puncture site closure devices Using catheters and wires Through and through wire (a.k.a bodyflossing) Buddy wire Catheter flushing Double flush technique Single flush technique Troubleshooting Sheaths Troubleshooting The sheath will not aspirate The sheath kinks Selective catheterization: keys to success Pre-procedure imaging Approximate positioning Catheter manipulation Catheter wire interaction Choosing your weapon Catheter handling Construction considerations Braiding Coating Visibility Sidewinder shape catheters Using the sidewinder Co-axial systems Vascular access Arterial puncture Passage of the guidewire Troubleshooting The wire will not advance beyond the needle tip The wire stops after a short distance Introduction of the catheter Commonly used arterial puncture sites Common femoral artery Antegrade puncture (Fig. 11.8) Arm approaches Brachial artery (Fig. 11.9) Radial artery Esoteric arterial access sites Popliteal artery (Fig. 11.10) Pedal arteries Translumbar aortic puncture Axillary artery Venous puncture Ultrasound guided vein puncture Commonly used venous access sites Common femoral vein (CFV) Internal jugular vein (IJV) Subclavian vein and axillary vein ‘Blind’ central vein puncture Ultrasound-guided jugular vein puncture Median cubital vein Esoteric venous access sites Inferior vena cava Hepatic vein Portal vein Renal vein Collateral veins Suggestions for further reading Haemostasis How to prevent haemorrhage and haematoma Bedrest post angiography Troubleshooting The bleeding doesn’t stop – there’s a range of escalation here Every time I release the pressure bleeding starts The groin is okay but the BP is dropping A large haematoma develops I can’t stop the bleeding no matter how hard I press Arterial closure devices Passive devices Active devices Suture-mediated closure devices Troubleshooting Only one suture end is captured The suture won’t slip The suture snaps Bleeding continues despite your best efforts External plug Troubleshooting Bleeding continues after deployment There is no pulse after deployment Suggestions for further reading Complications of angiography and vascular intervention Immediate complications Puncture site complications Haematoma Bleeding First aid False aneurysm Management of puncture site false aneurysms Ultrasound-guided compression Thrombin injection Troubleshooting If thrombosis does not occur The false aneurysm thromboses but a tongue of thrombus is seen in the artery The artery thromboses Other puncture site complications Thrombosis Arteriovenous fistula Nerve damage Intervention site complications Arterial dissection Arterial occlusion Arterial rupture Venous filling Remote problems Distal macroembolization Distal microembolization Cardiorespiratory failure Angiographic diagnosis Diagnostic digital subtraction angiography Lower limb arterial diagnosis Indications Equipment Procedure Access Catheterization Runs Additional views Iliac obliques Profunda oblique Focal stenoses Lateral foot views Troubleshooting Arterial bypass graft diagnosis Aims of graft angiography Equipment Procedure Access Catheterization Runs Troubleshooting Difficulty inserting the sheath Difficulty catheterizing the graft origin Difficulty visualizing the graft origin Upper limb arterial diagnosis Equipment Procedure Access Catheterization Runs Interpretation Troubleshooting Unable to catheterize an arch vessel Poor visualization of the distal vessels Aortic arch arterial diagnosis Equipment Procedure Catheterization Runs Interpretation Troubleshooting Renal arterial diagnosis Equipment Procedure Access Catheterization Runs Flush aortogram Selective angiography Troubleshooting Only one kidney seen, time to check how many were on the non-invasive imaging? Contrast in the superior mesenteric artery (SMA) obscures the right renal artery Unable to profile the renal artery ostia Angiography for potential live renal donors Renal transplant angiography Equipment Procedure Access Catheterization Runs Interpretation Troubleshooting Hepatic arterial diagnosis Equipment Procedure Access Catheterization Runs Troubleshooting Unable to pass a guidewire into the hepatic artery Unable to selectively catheterize the hepatic artery Spasm in the hepatic artery Mesenteric arterial diagnosis Mesenteric ischaemia Equipment Procedure Catheterization Runs Troubleshooting A vessel is seen on the AP arteriogram but cannot be identified on the lateral aortogram A smooth impression is seen on the superior aspect of the coeliac axis Mesenteric aneurysm Chronic gastrointestinal bleeding Acute lower gastrointestinal bleeding (LGIB) Before starting Equipment Procedure Access Catheterization Runs What to look for The usual suspects Angiodysplasia Diverticular disease Meckel’s diverticulum Tumour Interpretation If a bleeding site is identified Troubleshooting Bronchial and pulmonary angiographic diagnosis Bronchial artery angiography Bronchial artery anatomy Equipment Procedure Access Catheterization Runs What to look for Troubleshooting Unable to see bronchial arteries Unable to catheterize the bronchial arteries Pulmonary angiography Equipment Procedure Troubleshooting Failure to catheterize the pulmonary artery Pulsatile injection with poor peripheral pulmonary artery filling despite 40 mL at 20 mL/s Breathless patient and poor DSA images Complications Carotid arterial diagnosis Equipment Procedure Access Catheterization Arch aortogram Carotid and vertebral artery catheterization Runs Interpretation Troubleshooting Catheter ‘jumps’ around the aortic arch Unable to catheterize an arch vessel Unable to advance catheter into arch vessel The external carotid artery superimposes on the internal carotid artery Vascular measurement Trauma vascular diagnosis Signs of vascular injury Penetrating injury Blunt injury Blunt aortic injury Hepatic and splenic injury Renal injury Pelvic injury Peripheral vascular injury Suggestions for further reading Renal Mesenteric Hepatic Pulmonary Carotid angiography Calibrated angiography Trauma Angioplasty and stenting Basic principles Equipment Balloon diameter Balloon length Shaft lengths Sheaths Under pressure Inflation Deflation Procedure Vascular access Crossing the lesion Dilating the lesion Completion angiography Troubleshooting Unable to cross the lesion Unable to cross the lesion despite exhaustive efforts A guidewire perforation occurs The wire crosses the lesion but the catheter will not follow A dissection flap is seen post angioplasty There is a greater than 30% residual stenosis Distal embolization occurs Extravasation occurs post angioplasty Angioplasty and stenting of specific sites Aorta Procedure Access Catheterization Runs Complications Iliac arteries Procedure Access Catheterization Runs Complications Common femoral artery Superficial femoral artery Procedure Access Catheterization Runs Complications Tibial vessels Renal artery Intervention in renovascular disease Equipment Procedure Access Catheterization Dilation Complications Supra-aortic angioplasty and stenting Upper limb angioplasty Carotid angioplasty Cerebral protection devices Filter wires Flow reversal systems Vertebral artery intervention Venous angioplasty Suggestions for further reading Peripheral angioplasty Upper limb angioplasty Renal angioplasty Complications of angioplasty and stenting Stents and stent-grafts Stents Indications for stenting Stent terminology Balloon-mounted Self-expanding Material Additional properties Lattice or mesh Open or closed cell structure Markers Balloon-mounted stents Troubleshooting The stent moves proximal or distal to the balloon markers prior to deployment (Fig. 16.2) Self-expanding stents and stent-grafts Deploying self-expanding stents Pusher and sheath system Pusher and sheath incorporated into a single delivery catheter A note on using the Wallstent ‘Trigger’ and ‘screw’ systems Ripcord system Choosing that stent Guide to safe stenting Troubleshooting Ooops, I didn’t size the diameter correctly, my stent looks too small and looks as though it will migrate Balloon deployed stent Self-expanding stent Stent-grafts Stent-graft terminology Straight Tapered Birfucated Fenestrated Branched Stent-grafting – basic rules Spontaneous and iatrogenic arterial rupture Occlusive disease Suggestions for further reading Endovascular aneurysm repair (EVAR) EVAR terminology Endovascular abdominal aortic aneurysm repair (EVAR) Aneurysm exclusion with a straight stent-graft Endovascular thoracic aortic aneurysm repair (TEVAR) Emergency endovascular abdominal aortic aneurysm repair (E-EVAR) Assessment for endovascular stent-grafting What to look for Access: The common femoral and iliac arteries Contraindications Solutions Anchorage sites Contraindications Solutions Adequate visceral blood supply Contraindications Solutions Deployment of a modular bifurcated stent-graft (Fig. 17.6) Stent-graft deployment: a step-by-step guide Phase 1: surgical pause Troubleshooting Phase 2: access Troubleshooting Insufficient space to control the artery Severely diseased common femoral arteries Phase 3: Positioning Troubleshooting Unable to catheterize the renal artery Cannot see renal arteries Contrast does not reflux from the renal artery into the aorta Phase 4 Deployment of the body Troubleshooting The device starts to migrate cranially during deployment The device starts to migrate caudally during deployment The nose cone will not resheath Phase 5 Deployment of the contralateral limb Troubleshooting Direct catheterization of the contralateral limb from the iliac artery can be difficult in a large aneurysm Phase 6 Completion angiography (sometimes a misnomer as this is the start of all the trouble!) Troubleshooting Flow through the graft is very slow Suggestions for further reading Embolization General principles The target anatomy Level to block Which embolic agent Safety Pain control Key steps for safe embolization Embolic agents Coils and plugs Coil types Coil material Fibred coils Coil shapes Coatings Detachable coils Hydrogel coils Liquid coils What size coil? Diameter of the coil wire Unconstrained length Diameter of the formed coil Using coils Position the catheter Introducing coils into the catheter Standard coil pushers Microcatheter coil pushers Extruding coils Packing coils Completion angiography Troubleshooting Unable to obtain selective catheter position Unable to obtain a stable catheter position The delivery catheter is pushed back during coil deployment A coil is misplaced A coil jams in the delivery catheter Amplatzer vascular plug (AVP) Using the AVP Assess the target Suitability Access Catheterization Deployment Check angiogram Particulate embolic agents Gelfoam Gelfoam pledgets Using Gelfoam pledgets Gelfoam torpedoes Using Gelfoam torpedoes Polyvinyl alcohol Preparing PVA Using PVA Alternative permanent agents Autologous blood clot Liquid embolic agents Absolute alcohol Sodium tetradecyl sulphate Clinical scenarios Varicocoele Equipment Procedure Access Catheterization Runs Troubleshooting No reflux is seen The spermatic vein goes into spasm Uterine fibroid embolization (UFE) Assessment Equipment Technique Aftercare Complications Trauma Indication for embolization Contraindication to embolization Hepatic trauma Blunt hepatic trauma Splenic trauma Pelvic trauma Renal trauma Gastrointestinal bleeding Complications Post-embolization syndrome Non-target embolization Abscess formation Tissue necrosis Suggestions for further reading Thrombolysis and thrombectomy Thrombolysis Indications and contraindications Indications Contraindications Equipment Procedure Access Direct prosthetic graft puncture Techniques and regimens Procedural care Endpoints Adjunctive techniques Complications Thrombosuction Equipment Procedure Access Catheterization Technique Troubleshooting Thrombus cannot be aspirated A central core of thrombus is removed but extensive thrombus remains Thrombus embolizes distally Mechanical thrombectomy Equipment Procedure Access Catheterization Technique Troubleshooting The catheter will not pass down the vessel The Amplatz thrombectomy device stops working The catheter clears a central core but leaves residual thrombus The device does not clear the thrombus Suggestions for further reading Thrombolysis Percutaneous aspiration thrombectomy Mechanical thrombectomy Venous intervention IVC filters Indications for IVC filtration Equipment Procedure Access Catheterization Runs Positioning the filter Deploying the filter Bird’s nest filter Gunther tulip filter Filter removal Complications Access site thrombosis IVC perforation Incorrect deployment Late complications IVC thrombosis Structural failure of the filter Superior vena cava obstruction Assessing SVCO Treatment of SVCO Uncomplicated stenosis or occlusion SVCO complicated by thrombosis Equipment Procedure Access Catheterization Runs Technique Troubleshooting Poor flow or extensive collateral filling Both brachiocephalic veins are involved There is a large discrepancy in size between the venous segments to be stented The patient becomes hypoxic or hypotensive Inferior vena cava obstruction (IVCO) Iliac vein obstruction Transjugular intrahepatic porto-systemic shunt Anatomy for TIPS Guidance for TIPS procedure Equipment Procedure Access Catheterization Runs Further catheterization Puncturing the portal vein Catheterizing the portal vein Forming the TIPS tract Stenting the TIPS tract Finishing off Troubleshooting Unable to catheterize the hepatic vein Unable to hit the portal vein Hit an intrahepatic bile duct Hit the hepatic artery Hit peripheral portal vein Hit the main portal vein Unable to advance the TIPS catheter/sheath into portal vein The portal vein tears Residual pressure gradient post TIPS The patient is still bleeding Encephalopathy TIPS follow-up Transjugular liver biopsy Tunnelled central lines Learn your lines! Equipment Procedure Access Tunnelling Line insertion Line positioning Final assembly An additional note on dialysis lines Troubleshooting Arterial puncture Doubt about position Unable to advance the sheath Unable to introduce the line through the sheath Unable to aspirate blood from the line Kinking Awkward venous access Maintenance of tunnelled central lines How to strip Suggestions for further reading Venous intervention SVCO TIPS Central lines Haemodialysis access – imaging and intervention Fistula examination Graft examination Diagnostic imaging Arteriovenous fistulae Haemodialysis grafts Equipment Procedure Access Catheterization Runs Interpretation Troubleshooting Unable to puncture the fistula The arteries distal to the fistula do not fill Angioplasty and stenting Access Troubleshooting Unable to puncture the draining vein Unable to dilate a stenosis Rupture Spasm Thrombosis Direct AV fistulae Haemodialysis grafts Troubleshooting Uncertain anatomy Extravasation occurs during thrombolysis Intra-procedural thrombosis Suggestions for further reading Rendezvous and retrieval procedures The toolkit Amplatz Gooseneck snare (Figs 22.1, 22.2, see also Chapter 9, Equipment for Angiography, Fig. 9.13) The EnSnare (MD Tech) (Fig. 22.2) Clinical scenarios Catheter and guidewire fragments Embolization coils Stents Bullets and exciting projectiles Repositioning central venous lines Rendezvous, pull-through technique or ‘bodyflossing’ Suggestions for further reading Imaging guidance for intervention Ultrasound guidance Sterility Directing punctures CT guidance Patient positioning Fluoroscopic guidance Suggestions for further reading Equipment for non-vascular intervention Co-axial access set (Neff/Accustick) Torcon blue biliary manipulation catheter (Cook) Peel-away sheath Ureteric stent systems Biopsy and drainage Fine needle aspiration cytology and biopsy The patient Contraindications Abnormal clotting or platelets Vascular lesion Obstructed system Uncooperative patient Diagnosis irrelevant to management Which specimen – cytology or histology Fine needle aspiration cytology Cutting needle biopsy Manual biopsy needles Automated biopsy devices Aftercare Draining fluid collections and abscesses Assessing abscesses Which drain Drain size Drain type Diagnostic aspiration Equipment Procedure Troubleshooting Fluid cannot be aspirated Therapeutic drainage Procedure Follow-up Troubleshooting The drainage catheter will not advance into the collection The collection is loculated and does not drain freely The catheter drains initially but then stops Fever does not settle after 48 hours There is a sudden increase in drainage or a change in the composition of the effluent Biopsy and drainage of specific areas Liver Plugged liver biopsy Equipment Procedure Transjugular liver biopsy Anatomy Equipment Procedure Access Catheterization Runs Biopsy Kidney Adrenal glands Pancreas Retroperitoneum Pelvis Complications of biopsy and drainage Bleeding Perforation of a hollow viscus Pneumothorax Fistula Infection Tumour seeding of the biopsy tract Death Suggestions for further reading Pelvic Thoracic Liver Renal Adrenal Pancreas Percutaneous renal intervention Percutaneous nephrostomy Equipment Procedure Target zone Ultrasound-guided puncture Achieving drainage Troubleshooting Difficult visualization Aspiration of urine but cannot advance guidewire Unable to advance dilators/drainage catheter The pelvicalyceal system is undilated Renal transplant nephrostomy Antegrade ureteric stent insertion Indications Equipment Procedure Troubleshooting Unable to negotiate the stricture with a guidewire Unable to advance the catheter through the stricture Unable to advance the stent through the stricture The pusher becomes impacted in the stent The retraction sutures are entangled with the stent Complications of nephrostomy and antegrade ureteric stenting Disruption of the renal pelvis/extravasation of contrast Bleeding Inadvertent puncture of adjacent structures Percutaneous nephrolithotomy (PCNL) Accessing the system Dilating the tract Removing stone Which tube to leave behind? Complications Suggestions for further reading Biliary intervention Percutaneous transhepatic cholangiography Equipment Procedure Planning your approach Right-sided punctures Left-sided punctures Interpretation Troubleshooting There is ascites You do not hit a bile duct at the first attempt Contrast extravasates from the bile duct The left ducts do not fill Extensive intraluminal filling defects are seen The patient has a rigor on the table Percutaneous biliary drainage Equipment Procedure Which drainage catheter? Straight drain Pigtail drain Internal/external drain Troubleshooting Guidewire or catheter reluctant to advance Initial cholangiogram fades Unable to cross the lesion with the guidewire Unable to cross the lesion with the catheter Unable to cross the lesion with the drain or stent Biliary bleeding Drainage stops Biliary stenting Plastic stents Metal stents Roux loop access Equipment Procedure Access Catheterization Percutaneous gallbladder drainage (cholecystostomy) Percutaneous fluoroscopic gastrostomy Equipment Technique RIG How to use T fasteners/anchors PIG Aftercare Results Troubleshooting Unable to pass a nasogastric tube Difficult access Difficulty getting the catheter through the gastric wall Difficulty accessing the oesophagus retrogradely during a PIG procedure Access is lost after tract dilation The gastrostomy tube falls out after insertion Suggestions for further reading Gastrointestinal stent insertion Oesophageal stent insertion Equipment Procedure Aftercare Retrievable stents Results Troubleshooting The stent migrates through the cardia The stent occludes The lesion is high in the oesophagus The patient develops chest pain post deployment Oesophageal fistulae and perforations Gastric oulet/duodenal stent placement Colorectal stent placement Equipment Technique Results Troubleshooting Can’t negotiate the stricture Oops, I’ve perforated the bowel The stent has migrated Suggestions for further reading Tumour ablation Radiofrequency ablation RFA systems Cookbook Covidien Boston Scientific Rita Imaging guidance for RFA Pitfalls/limitations/suboptimal treatment Adjunctive techniques Minimizing collateral damage Improving access Complications of RFA Complications of electrode placement Complications of thermal therapy Organ-specific complications Metal implants Specific RFA applications Liver Kidney Adrenals Bone tumours Osteoid osteoma Lung Microwave (MW) ablation Cryoablation Advantages of cryoablation over RFA and MWA Disadvantage of cryoablation Suggestions for further reading Respiratory system Biopsy of pulmonary and pleural masses Planning Aspiration versus cutting biopsies Post-procedural care Complications Pleural effusions Thoracocentesis Bronchial artery embolization Anatomy Technique – CFA access Interpretation Embolization Complications Tracheobronchial stenting Preparation Technique Suggestions for further reading