Interventional Radiology: Indications and Best Practices

 

Am Fam Physician. 2019 May 1;99(9):547-556.

  See related AFP Community Blog post: Introducing Dr. Mike Arnold, the first Jay Siwek Medical Editing Fellow

Author disclosure: No relevant financial affiliations.

Interventional radiology employs image-guided techniques to perform minimally invasive procedures for diagnosis and treatment. Interventional radiology is often used to place central venous catheters and subcutaneous ports, with some evidence of benefit over surgical placement. Arterial embolization procedures are used to manage many types of hemorrhage and are highly effective for severe postpartum hemorrhage. Vascular interventions, such as endovascular treatment of varicosities, acute limb ischemia, and pulmonary embolism, are superior to surgical interventions. For chronic limb ischemia and deep venous thrombosis, the choice of therapy is not as clear. Inferior vena cava filters can be placed and removed endovascularly, but there is a significant risk of complications that increases over time. Vascular interventions can be effective for scrotal varicocele and uterine fibroids, although fibroid treatment is limited by high recurrence rates. Image-guided percutaneous drainage and biopsy have become standard of care. Interventional approaches are being used in oncology for local diagnosis and treatment. Percutaneous ablation and targeted delivery of chemotherapy and radiation therapy are being developed as alternatives when surgery is not practical. Vertebroplasty and kyphoplasty provide significant pain and functional improvement in patients with spinal metastases.

Interventional radiology employs image-guided techniques to perform minimally invasive procedures, providing lower-risk alternatives to many traditional medical and surgical therapies. Since the advent of interventional radiology in the 1960s, its role has expanded to encompass the diagnosis and treatment of diseases across multiple body systems.1  The treatments discussed in this article represent a sample of what interventional radiology can offer to family physicians. Guidelines regarding procedural bleeding risks and recommended anticoagulation management are shown in Table 1.2,3

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Overall complications and costs are reduced when ports are placed with interventional radiography rather than surgically.

B

57

Endovascular treatments of abdominal aortic aneurysms have improved 30-day mortality and equivalent total mortality compared with surgery.

A

14

Endovascular treatments for varicose veins have similar success rates and lower complication rates than surgery.

A

17, 18

Transarterial embolization for postpartum hemorrhage has a high success rate and can preserve fertility.

B

24, 29

Catheter-directed thrombolysis for massive and submassive pulmonary embolism has mortality benefits over anticoagulation alone.

B

4951

Interventional percutaneous drainage and biopsy procedures have success rates that are at least equivalent to open surgical approaches.

B

5860, 64, 65, 67, 68

Vertebroplasty and kyphoplasty provide significant pain and functional benefits to patients with painful spinal metastases.

B

78


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Overall complications and costs are reduced when ports are placed with interventional radiography rather than surgically.

B

57

Endovascular treatments of abdominal aortic aneurysms have improved 30-day mortality and equivalent total mortality compared with surgery.

A

14

Endovascular treatments for varicose veins have similar success rates and lower complication rates than surgery.

A

17, 18

Transarterial embolization for postpartum hemorrhage has a high success rate and can preserve fertility.

B

24, 29

Catheter-directed thrombolysis for massive and submassive pulmonary embolism has mortality benefits over anticoagulation alone.

B

4951

Interventional percutaneous drainage and biopsy procedures have success rates that are at least equivalent to open surgical approaches.

B

5860, 64, 65, 67, 68

Vertebroplasty and kyphoplasty provide significant pain and functional benefits to patients with painful spinal metastases.

B

78


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

TABLE 1.

Guidelines for Percutaneous Interventions

CategoryBleeding risk of procedure
LowMediumHigh

Procedures

Catheter exchange/removal Dialysis access Inferior vena cava filter placement Joint aspiration/injection Nontunneled central venous catheter Paracentesis Superficial aspiration/biopsy Thoracentesis Thyroid biopsy

Abscess drainage Angiography Chemoembolization/radioembolization Enteric tube placement Organ biopsy Percutaneous cholecystostomy Spinal procedure Transjugular liver biopsy Tunneled central venous catheter/subcutaneous port placement Uterine fibroid embolization Venous intervention

Biliary intervention Nephrostomy tube placement Radiofrequency ablation Renal biopsy Transjugular intrahepatic portosystemic shunt

Recommended INR and platelet thresholds

INR ≤ 2.0 Platelets ≥ 50 × 103 per μL (50 × 109 per L)

INR ≤ 1.5 Platelets ≥ 50 × 103 per μL

INR ≤ 1.5 Platelets ≥ 50 × 103 per μL

How long before procedure a medication should be stopped (based on bleeding risk)

 Apixaban (Eliquis)

One day

Two days

Three days

 Aspirin

Five days

 Clopidogrel (Plavix)

Zero to five days

Five days

Five days

 Dabigatran (Pradaxa)

One day

Two days

Three days

 Fondaparinux (Arixtra)

One day

36 hours

Two days

 Low-molecular-weight heparin (enoxaparin [Lovenox])

12 hours (one dose)

12 hours (one dose)

12 to 24 hours (one or two doses)

 NSAIDs

One to 10 days*

 Rivaroxaban (Xarelto)

One day

Two days

Two days

 Unfractionated heparin (intravenous)

One hour

Four hours

Four hours

 Unfractionated heparin (subcutaneous)

Four hours

Four hours

Six hours

 Warfarin (Coumadin)

Three to five days

Five days

Five days


Note: Based on the Society of Interventional Radiology Consensus Guidelines.

INR = international normalized ratio; NSAID = nonsteroidal anti-inflammatory drug.

*—The recommendation differs based on the medication duration. Before high-risk procedures, short-duration NSAIDs (e.g., ibuprofen) should be withheld for one day, intermediate-duration NSAIDs (e.g., naproxen) should be withheld for two or three days, and long-duration NSAIDs (e.g., meloxicam) should be withheld for 10 days.

Information from references 2 and 3.

TABLE 1.

Guidelines for Percutaneous Interventions

CategoryBleeding risk of procedure
LowMediumHigh

Procedures

Catheter exchange/removal Dialysis access Inferior vena cava filter placement Joint aspiration/injection Nontunneled central venous catheter Paracentesis Superficial aspiration/biopsy Thoracentesis Thyroid biopsy

Abscess drainage Angiography Chemoembolization/radioembolization Enteric tube placement Organ biopsy Percutaneous cholecystostomy Spinal procedure Transjugular liver biopsy Tunneled central venous catheter/subcutaneous port placement Uterine fibroid embolization Venous intervention

Biliary intervention Nephrostomy tube placement Radiofrequency ablation Renal biopsy Transjugular intrahepatic portosystemic shunt

Recommended INR and platelet thresholds

INR ≤ 2.0 Platelets ≥ 50 × 103 per μL (50 × 109 per L)

INR ≤ 1.5 Platelets ≥ 50 × 103 per μL

INR ≤ 1.5 Platelets ≥ 50 × 103 per μL

How long before procedure a medication should be stopped (based on bleeding risk)

 Apixaban (Eliquis)

One day

Two days

Three days

 Aspirin

Five days

 Clopidogrel (Plavix)

Zero to five days

Five days

Five days

 Dabigatran (Pradaxa)

One day

Two days

Three days

 Fondaparinux (Arixtra)

One day

36 hours

Two days

 Low-molecular-weight heparin (enoxaparin [Lovenox])

12 hours (one dose)

12 hours (one dose)

12 to 24 hours (one or two doses)

 NSAIDs

One to 10 days*

 Rivaroxaban (Xarelto)

One day

Two days

Two days

 Unfractionated heparin (intravenous)

One hour

Four hours

Four hours

 Unfractionated heparin (subcutaneous)

Four hours

Four hours

Six hours

 Warfarin (Coumadin)

Three to five days

Five days

Five days


Note: Based on the Society of Interventional Radiology Consensus Guidelines.

INR = international normalized ratio; NSAID = nonsteroidal anti-inflammatory drug.

*—The recommendation differs based on the medication duration. Before high-risk procedures, short-duration NSAIDs (e.g., ibuprofen) should be withheld for one day, intermediate-duration NSAIDs (e.g., naproxen) should be withheld for two or three days, and long-duration NSAIDs (e.g., meloxicam) should be withheld for 10 days.

Information from references 2 and 3.

Placement of Indwelling Catheters and Ports

Central venous catheters and subcutaneous ports offer short- and long-term solutions for the administration of intravenous therapies (Figure 1). Interventional radiology uses ultrasound and fluoroscopic guidance to perform central venous cannulation. Nontunneled catheters may be converted to tunneled catheters later for long-term access.

 Enlarge     Print

FIGURE 1.

Central venous catheters. (A) Nontunneled catheter and (B) tunneled catheter for dialysis. (C) Peripherally inserted central catheter. (D) Subcutaneous port.


FIGURE 1.

Central venous catheters. (A) Nontunneled catheter and (B) tunneled catheter for dialysis. (C) Peripherally inserted central catheter. (D) Subcutaneous port.

Venous access methods have variable infection risks (Table 2).4 Nontunneled catheters have the highest infection rate over time (2.7 infections per 1,000 days vs. 1.6 infections for tunneled catheters).4 Infections occur in one-fifth of patients with tunneled catheters because of prolonged placement.4 Subcutaneous ports improve infection rates and are commonly used for recurrent chemotherapy infusions.4 Overall complications and costs are reduced when ports are placed with interventional radiography rather than surgically, with reported savings of more than $1,500 because of more rapid procedure and turnover times.57

 Enlarge     Print

TABLE 2.

Risk of Bloodstream Infection with Different Intravascular Devices

Intravascular device*Bloodstream infections
Average days placedPercentage of devicesPer 1,000 days

Peripheral intravenous catheter

2.6

0.1

0.5

Midline catheter

18

0.4

0.2

Peripherally inserted central catheter

30

3.1

1.1

Nontunneled central venous catheter

16

4.4

2.7

Tunneled central venous catheter

133

21.2

1.6

Subcutaneous port

327

3.6

0.1


*—In order of least to most invasive.

Information from reference 4.

TABLE 2.

Risk of Bloodstream Infection with Different Intravascular Devices

Intravascular device*Bloodstream infections
Average days placedPercentage of devicesPer 1,000 days

Peripheral intravenous catheter

2.6

0.1

0.5

Midline catheter

18

0.4

0.2

Peripherally inserted central catheter

30

3.1

1.1

Nontunneled central venous catheter

16

4.4

2.7

Tunneled central venous catheter

133

21.2

1.6

Subcutaneous port

327

3.6

0.1


*—In order of least to most invasive.

Information from reference 4.

Arterial Interventions

PERIPHERAL ARTERY DISEASE INTERVENTIONS

Peripheral artery disease affects 8.5 million Americans and up to 20% of patients older than 60 years.8 Patients who develop limb ischemia or lifestyle-limiting claudication despite medical therapy are candidates for revascularization. Endovascular techniques include angioplasty, stenting, atherectomy, and precise antithrombotic medication delivery.

For chronic limb ischemia, a large trial found that angioplasty has lower morbidity, length of hospitalization, and cost but higher mortality than surgical revascularization after two years.9 Therefore, angioplasty is limited to patients with shorter life expectancy.9 Two trials of patients with acute limb ischemia demonstrated identical overall and amputation-free survival rates for percutaneous thrombolysis and surgical thrombectomy.10,11 Improvements in mechanical thrombectomy since these trials were conducted may have improved outcomes but have not been compared with surgery.12

AORTIC ANEURYSM REPAIR

Screening programs have led to increased detection of abdominal aortic aneurysms. Endovascular aortic repair uses fluoroscopic guidance to deploy a metallic stent graft (an impermeable fabric tube supported by a wire stent) to span an aneurysmal segment13 (Figure 2). A systematic review showed that endovascular treatments have improved 30-day mortality and equivalent total mortality compared with surgery.14

 Enlarge     Print

FIGURE 2.

Endovascular aneurysm repair. (A) Preintervention digital subtraction angiography demonstrating an infrarenal abdominal aortoiliac aneurysm. (B) Digital subtraction angiography following endovascular placement of a stent graft within the aneurysm, restoring arterial size.


FIGURE 2.

Endovascular aneurysm repair. (A) Preintervention digital subtraction angiography demonstrating an infrarenal abdominal aortoiliac aneurysm. (B) Digital subtraction angiography following endovascular placement of a stent graft within the aneurysm, restoring arterial size.

Venous Interventions

Chronic venous disease encompasses a wide disease spectrum, with an estimated 22 million women and 11 million men in the United States affected by varicose veins.15 Symptomatic patients with varicose veins that do not respond to conservative management may benefit from endovenous laser therapy, radiofrequency ablation, and sclerotherapy.16 These treatments damage the endothelium, ultimately ablating varicosities. A recent systematic review found comparable long-term outcomes, including varicosity recurrence, in patients who received endovenous laser therapy or radiofrequency ablation vs. surgical intervention for saphenous insufficiency.17 Cosmetic outcomes do not differ between interventional and surgical techniques.15 Fewer complications, including bleeding, infection, and paresthesia, have been observed with endovenous laser therapy compared with surgical high ligation.18

Treatments for Hemorrhage

TRANSARTERIAL EMBOLIZATION

Transarterial embolization involves insertion of hemostatic material through a catheter into a target artery to stop hemorrhage19 (Figure 3). Hemostatic agents include temporary embolic material, such as gelatin sponges, that degrade within days to weeks or more permanent devices, such as platinum coils and polyvinyl alcohol spheres.20  Transarterial embolization is effective for many types of acute hemorrhage (Table 3).2128 Common complications of the procedure include a postembolization syndrome with transient fever, pain, and nausea. Less common but more severe complications include vessel injury, local necrosis, infection, and venous thromboembolism.29

 Enlarge     Print

FIGURE 3.

Bronchial artery embolization. (A) Digital subtraction angiography of the left bronchial artery demonstrating active arterial extravasation (arrow) from a left lung mass. (B) Postembolization digital subtraction angiography with cessation of blood flow (arrow) with preserved flow to nontarget branches.


FIGURE 3.

Bronchial artery embolization. (A) Digital subtraction angiography of the left bronchial artery demonstrating active arterial extravasation (arrow) from a left lung mass. (B) Postembolization digital subtraction angiography with cessation of blood flow (arrow) with preserved flow to nontarget branches.

 Enlarge     Print

TABLE 3.

Indications for Transarterial Embolization for Acute Hemorrhage

Type of hemorrhageEvidence for transarterial embolization

Gastrointestinal tract bleed, lower

85% to 97% success rate in patients with diverticular bleeds, with 5% to 10% ischemic complications in a meta-analysis of case series21

Gastrointestinal tract bleed, upper

63% to 97% success rate in small case series22

Hemoptysis

70% to 99% success rate in a systematic review of observational studies23

Postpartum hemorrhage

89% success rate in a systematic review24

Postsurgical

Case series show 100% success rate after orthopedic surgery and abdominal anastomosis25,26

Retroperitoneal bleed

100% success rate in small case series27

Trauma

Trials show greater than 90% success rate in patients with spleen, liver, or kidney injuries and greater than 85% success rate in patients with pelvic fractures in multiple case series28


Information from references 21 through 28.

TABLE 3.

Indications for Transarterial Embolization for Acute Hemorrhage

Type of hemorrhageEvidence for transarterial embolization

Gastrointestinal tract bleed, lower

85% to 97% success rate in patients with diverticular bleeds, with 5% to 10% ischemic complications in a meta-analysis of case series21

Gastrointestinal tract bleed, upper

63% to 97% success rate in small case series22

Hemoptysis

70% to 99% success rate in a systematic review of observational studies23

Postpartum hemorrhage

89% success rate in a systematic review24

Postsurgical

Case series show 100% success rate after orthopedic surgery and abdominal anastomosis25,26

Retroperitoneal bleed

100% success rate in small case series27

Trauma

Trials show greater than 90% success rate in patients with spleen, liver, or kidney injuries and greater than 85% success rate in patients with pelvic fractures in multiple case series28


Information from references 21 through 28.

Approximately 1% of pregnancies are complicated by severe postpartum hemorrhage, which causes 14% of pregnancy-related deaths.30,31 Pelvic transarterial embolization can be used to treat severe postpartum hemorrhage. A systematic review of 1,739 cases of severe postpartum hemorrhage showed that transarterial embolization achieved hemostasis in 89% of cases, with 2% of successful procedures occurring after ineffective emergency hysterectomy.24 Up to 12% of patients develop uterine synechiae after transarterial embolization, but the risk is less than with uterine compressive sutures or curettage.32 A systematic review showed a subsequent pregnancy rate of 76% after transarterial embolization, with no increase in miscarriage or intrauterine growth restriction.29 However, these pregnancies have an elevated risk of invasive placental disorders and a nearly 20% risk of postpartum hemorrhage.33

Reproductive Interventions

UTERINE FIBROID EMBOLIZATION

As many as 30% of women have pelvic pain or bleeding due to fibroids in their lifetime.34 Current practice guidelines support uterine fibroid embolization as an alternative to hormonal therapy and myomectomy for the treatment of women with symptomatic fibroids who wish to retain fertility.35

During uterine fibroid embolization, small particles are injected through the uterine arteries after selective catheterization, with the goal of relieving symptoms by shrinking the fibroids.36 A systematic review showed equivalent patient satisfaction and clinical success between uterine fibroid embolization and myomectomy.37 However, these improvements are not always sustained. A Cochrane review showed that up to 32% of patients receiving uterine fibroid embolization require surgical treatment within two years.38

INTERVENTIONS FOR SCROTAL VARICOCELES

Varicoceles affect up to 15% of males and are the most common diagnosis in infertile men.39 Varicoceles are most often treated in cases of orchialgia, infertility, or reduced testicular size in adolescents.39 Endovascular therapy embolizes the affected spermatic vein using coils or sclerosants. Studies have shown that gonadal vein embolization is effective for relieving orchialgia, with 87% of 154 patients having complete pain relief at 39 months in one review.40 A Cochrane review of low-quality studies that did not differentiate between surgery and embolization suggests varicocele treatment improves fertility.41

Treatments for Venous Thromboembolism

CATHETER-DIRECTED THROMBOLYSIS FOR DVT

Postthrombotic syndrome, characterized by limb pain and sensory and skin changes, is an important long-term complication of deep venous thrombosis (DVT). The complication occurs in up to one-half of patients with DVT despite anticoagulation.42 Catheter-directed thrombolysis (Figure 4) delivers thrombolytics to the clot, which can be augmented with endovascular mechanical manipulation and ultrasound-enhanced catheterization.43,44

 Enlarge     Print

FIGURE 4.

Catheter-directed thrombolysis of deep venous thrombosis. (A) Digital subtraction angiography of the left femoral vein demonstrating marbled filling defects within the vein from deep venous thrombosis. (B) Digital subtraction angiography following catheter-directed thrombolysis and thrombectomy with near elimination of thrombus and restoration of blood flow.


FIGURE 4.

Catheter-directed thrombolysis of deep venous thrombosis. (A) Digital subtraction angiography of the left femoral vein demonstrating marbled filling defects within the vein from deep venous thrombosis. (B) Digital subtraction angiography following catheter-directed thrombolysis and thrombectomy with near elimination of thrombus and restoration of blood flow.

Although the use of thrombolytic therapy has been studied to prevent postthrombotic syndrome in patients with DVT, its effectiveness is uncertain.45 A 2016 Cochrane review showed that catheter-directed thrombolysis has a number needed to treat (NNT) of 7 to prevent one case of postthrombotic syndrome within five years, and a number needed to harm (NNH) of 36 for bleeding.46 However, in a subsequent large, multicenter, randomized trial, catheter-directed thrombolysis did not reduce postthrombotic syndrome compared with anticoagulation after two years but decreased postthrombotic severity.47 Further research is needed to clarify the role of catheter-directed thrombolysis in DVT treatment.

CATHETER-DIRECTED THROMBOLYSIS FOR PE

Catheter-directed thrombolysis has also been studied for the treatment of pulmonary embolism (PE). Current practice guidelines recommend systemic thrombolysis for massive PE.48 However, a meta-analysis of noncontrolled trials favors catheter-directed thrombolysis over systemic thrombolysis, with an NNT of 13 for preventing death and 5 for preventing major complications.49,50 For submassive PE, guidelines primarily recommend anticoagulation, with consideration of catheter-directed thrombolysis.48 Systemic thrombolysis lowers mortality over anticoagulation with an NNT of 65, but it has an NNH of 19 for major bleeding.51 Catheter-directed thrombolysis has the same mortality benefit as systemic thrombolysis with less major bleeding, improving the NNH to 41.51

INFERIOR VENA CAVA FILTERS

Inferior vena cava filters are used in up to 13% of patients with venous thromboembolism.52,53 Filters can be placed and retrieved via endovascular approaches (Figure 5). Most guidelines recommend inferior vena cava filters when anticoagulation is contraindicated or PE recurs despite anticoagulation.54 A recent systematic review involving more than 4,000 patients showed that the use of inferior vena cava filters has an NNT of 20 to prevent PE and an NNH of 50 for recurrent DVT.55  There was no difference in absolute or PE-related mortality between patients with and without filters. Because complications from inferior vena cava filters increase over time (Table 4),56 the U.S. Food and Drug Administration issued warnings about increases in adverse effects from inferior vena cava filters, recommending prompt removal when indications allow.53 Inferior vena cava filter placement was reduced after these warnings, yet only 30% of placed filters are removed during the patient’s lifetime.53,54

 Enlarge     Print

FIGURE 5.

Inferior vena cava (IVC) filter placement. (A) Preprocedural digital subtraction angiography of the IVC with the renal veins (arrows). (B) Postdeployment venogram showing infrarenal IVC filter placement.


FIGURE 5.

Inferior vena cava (IVC) filter placement. (A) Preprocedural digital subtraction angiography of the IVC with the renal veins (arrows). (B) Postdeployment venogram showing infrarenal IVC filter placement.

 Enlarge     Print

TABLE 4.

Risks of Adverse Effects with Inferior Vena Cava Filters Over Time

Adverse effectRisk (%) since placement
Up to one monthOne to six monthsSix to 24 months

Deep venous thrombosis

0.3

1

5

Filter emboli

0.1

0.6

2

Filter fracture

0.02

0.1

0.4

Filter migration

0.2

0.8

3

Inferior vena cava occlusion

0.2

0.8

3

Inferior vena cava penetration

0.06

0.3

1

Retrieval complication

3

3

4


Information from reference 56.

TABLE 4.

Risks of Adverse Effects with Inferior Vena Cava Filters Over Time

Adverse effectRisk (%) since placement
Up to one monthOne to six monthsSix to 24 months

Deep venous thrombosis

0.3

1

5

Filter emboli

0.1

0.6

2

Filter fracture

0.02

0.1

0.4

Filter migration

0.2

0.8

3

Inferior vena cava occlusion

0.2

0.8

3

Inferior vena cava penetration

0.06

0.3

1

Retrieval complication

3

3

4


Information from reference 56.

Percutaneous Drainage and Biopsy

Image-guided percutaneous drainage and biopsy are safe, well-tolerated procedures and can be performed in nearly any part of the body.5760 The benefits of percutaneous drainage are well-established and reflected in current practice guidelines.61 Indications include further characterization of abnormal fluid collections, definitive drainage, or partial drainage before definitive surgery.62 Patients with abscesses larger than 3 cm are usually considered candidates for drain placement, whereas patients with smaller abscesses or who need sterile collections can be treated with aspiration or antibiotic therapy alone.63 Overall, the outcomes of percutaneous drainage are at least equivalent to open surgical approaches, with possible reductions in morbidity, length of hospital stay, and cost.64,65

Image guidance can be used for biopsies in a nontargeted fashion or to sample a specific mass. For superficial head and neck masses, such as in the lymph nodes, salivary glands, or thyroid, ultrasonography is commonly used. Guidelines recommend fine-needle aspiration for concerning thyroid lesions, but nearly 30% of samples are nondiagnostic.66,67 Core needle biopsies improve sample adequacy to 95%, although negative predictive values vary from 69% to 93% depending on site.68 Biopsy of deeper head and neck masses often requires computed tomography guidance for optimal visualization to avoid high-risk structures.69 Small studies show that computed tomography–guided biopsies provide adequate samples from 73% to 96% of deep neck lesions.70,71

Liver masses can be biopsied with high accuracy, although rates of needle tract seeding approach 5% in patients with hepatocellular carcinoma.72 Kidney mass sampling is often unnecessary because of high rates of benign and indolent disease but has high accuracy for characterizing indeterminate lesions.73 Computed tomography–guided transthoracic sampling of peripheral lung nodules has a much higher sensitivity than ultrasound-guided transbronchial biopsy, although it has a 1% rate of pneumothorax requiring a chest tube.74 In children, biopsy of soft tissue masses has an accuracy of more than 95%, with most lesions amenable to ultrasound guidance because of proximity to the skin surface.75

Interventional Oncology

Many interventional radiology techniques are used to treat solid tumors.76 Transarterial therapies include embolization (Figure 6) and targeted delivery of chemotherapy or radiation therapy. Tumors can be ablated by radiofrequency ablation, microwave ablation, cryoablation, or irreversible electroporation. Other interventional treatments can be used to ameliorate mass effects of tumors, including percutaneous drainage or stenting. Table 5 lists common interventional oncology treatments.76

 Enlarge     Print

FIGURE 6.

Hepatic transarterial chemoembolization. (A) Axial fat-suppressed T1 contrast-enhanced image demonstrates a round, arterially enhancing mass (arrow) in the right hepatic lobe consistent with hepatocellular carcinoma. (B) Digital subtraction angiography with catheter selection of the right hepatic artery shows vascularity of the right hepatic tumor (arrows). (C) Intraprocedural axial cone beam computed tomography delineates tumor vascular supply for selective branch embolization. (D) Follow-up axial fat-suppressed T1 contrast-enhanced image shows no residual enhancement consistent with necrosis of the tumor.


FIGURE 6.

Hepatic transarterial chemoembolization. (A) Axial fat-suppressed T1 contrast-enhanced image demonstrates a round, arterially enhancing mass (arrow) in the right hepatic lobe consistent with hepatocellular carcinoma. (B) Digital subtraction angiography with catheter selection of the right hepatic artery shows vascularity of the right hepatic tumor (arrows). (C) Intraprocedural axial cone beam computed tomography delineates tumor vascular supply for selective branch embolization. (D) Follow-up axial fat-suppressed T1 contrast-enhanced image shows no residual enhancement consistent with necrosis of the tumor.

 Enlarge     Print

TABLE 5.

Examples of Interventional Oncology Treatments

Embolization

Percutaneous drainage/stenting

Embolization of arterial supply to hepatic tumor (chemotherapy or radiation source can be added to embolization)

Biliary decompression and stenting: percutaneous transhepatic biliary drainage, cholecystotomy

Portal vein embolization to induce liver hypertrophy

Transjugular intrahepatic portosystemic shunt placement

Renal arterial embolization for renal cell carcinoma

Urinary decompression: percutaneous nephrostomy, ureteral stenting

Transarterial embolization of bone tumors

Percutaneous ablation

Vertebroplasty/kyphoplasty

Cryoablation: renal cell carcinoma, liver tumors, lung tumors

Pain control in metastatic spine lesions

Irreversible electroporation: liver tumors, pancreatic tumors

Microwave ablation: liver tumors, lung tumors

Radiofrequency ablation: liver tumors, renal cell carcinoma, lung tumors, spinal metastases


Information from reference 76.

TABLE 5.

Examples of Interventional Oncology Treatments

Embolization

Percutaneous drainage/stenting

Embolization of arterial supply to hepatic tumor (chemotherapy or radiation source can be added to embolization)

Biliary decompression and stenting: percutaneous transhepatic biliary drainage, cholecystotomy

Portal vein embolization to induce liver hypertrophy

Transjugular intrahepatic portosystemic shunt placement

Renal arterial embolization for renal cell carcinoma

Urinary decompression: percutaneous nephrostomy, ureteral stenting

Transarterial embolization of bone tumors

Percutaneous ablation

Vertebroplasty/kyphoplasty

Cryoablation: renal cell carcinoma, liver tumors, lung tumors

Pain control in metastatic spine lesions

Irreversible electroporation: liver tumors, pancreatic tumors

Microwave ablation: liver tumors, lung tumors

Radiofrequency ablation: liver tumors, renal cell carcinoma, lung tumors, spinal metastases


Information from reference 76.

TREATMENTS FOR BONE METASTASES

Spinal metastases occur in two-thirds of patients with metastatic cancer, and 30% of these patients have significant pain.77 Vertebroplasty involves the percutaneous injection of cement into the affected vertebrae, whereas kyphoplasty adds balloon inflation to restore vertebral height before cement injection. Both techniques are effective, with improvement in short-term pain in more than 90% of patients and functional improvements in more than 60% of patients.78 Reduction in local cancer recurrence has been observed after vertebroplasty, likely secondary to cytotoxic effects and heat from curing cement.79 Asymptomatic extrusion of cement from the vertebral body is common and leads to neurologic or vascular complications in up to 5% of patients.80 These procedures are less likely to benefit patients with osteoporotic vertebral compression fractures.81

LIVER-DIRECTED THERAPIES

The liver is the most common site of cancer metastases, presenting in 48% of metastatic breast cancers and up to 80% of metastatic colon cancers.82 Hepatocellular carcinoma, typically seen with cirrhosis, is less common than metastasis but has high mortality.83 Surgical resection of liver metastases is associated with higher survival than radio-frequency ablation but is often not feasible.84,85 Less than one-half of patients are candidates for resection, even after adjuvant chemotherapy.86 Quality-adjusted survival after radiofrequency ablation appears to be improved over no intervention and over surgery for smaller (less than 3 cm) tumors.86 Other liver-directed therapies can be palliative, such as placement of transjugular intrahepatic portosystemic shunts or biliary drainage procedures.76

This article updates a previous article by Ray.87

Data Sources: PubMed searches were completed using the key terms interventional radiology, catheter-directed thrombolysis, and percutaneous. After the important interventions were identified, searches were performed for each modality. The searches included systematic reviews, meta-analyses, randomized controlled trials, and review articles. We also searched the Cochrane database, Essential Evidence Plus, and Clinical Evidence. In addition, references in these resources were searched. Search dates: January 2018, March 2018, April 2018, and January 2019.

Figures 1 through 6 are property of the Department of Defense.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Army or Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. government.

The Authors

show all author info

MICHAEL J. ARNOLD, MD, is a faculty member in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md. At the time this article was written, he was a faculty member in the Department of Family Medicine at Naval Hospital Jacksonville (Fla)....

JONATHAN J. KEUNG, MD, is an interventional radiologist at the Walter Reed National Military Medical Center, Bethesda.

BRENT MCCARRAGHER, MD, is a radiology resident at the Walter Reed National Military Medical Center.

Address correspondence to Michael J. Arnold, MD, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814 (e-mail: michael.arnold@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

Editor's Note: Dr. Arnold is a medical editing fellow for AFP.

References

show all references

1. Society of Interventional Radiology. What is interventional radiology? https://www.sirweb.org/patients/what-is-interventional-radiology/. Accessed December 15, 2018....

2. Patel IJ, Davidson JC, Nikolic B, et al.; Standards of Practice Committee of the Society of Interventional Radiology. Addendum of newer anticoagulants to the SIR consensus guideline. J Vasc Interv Radiol. 2013;24(5):641–645.

3. Jaffe TA, Raiff D, Ho LM, Kim CY. Management of anticoagulant and antiplatelet medications in adults undergoing percutaneous interventions [published correction appears in AJR Am J Roentgenol. 2017;208(3):695–705]. AJR Am J Roentgenol. 2015;205(2):421–428.

4. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159–1171.

5. Foley MJ. Radiologic placement of long-term central venous peripheral access system ports (PAS Port): results in 150 patients. J Vasc Interv Radiol. 1995;6(2):255–262.

6. Sticca RP, Dewing BD, Harris JD. Outcomes of surgical and radiologic placed implantable central venous access ports. Am J Surg. 2009;198(6):829–833.

7. LaRoy JR, White SB, Jayakrishnan T, et al. Cost and morbidity analysis of chest port insertion: interventional radiology suite versus operating room. J Am Coll Radiol. 2015;12(6):563–571.

8. Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 2014;31(4):378–388.

9. Adam DJ, Beard JD, Cleveland T, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366(9501):1925–1934.

10. Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg. 1994;220(3):251–266.

11. Ouriel K, Veith FJ, Sasahara AA; TOPAS Investigators. Thrombolysis or peripheral arterial surgery: phase I results. J Vasc Surg. 1996;23(1):64–73.

12. Kasirajan K, Gray B, Beavers FP, et al. Rheolytic thrombectomy in the management of acute and subacute limb-threatening ischemia. J Vasc Interv Radiol. 2001;12(4):413–421.

13. Gordon PA, Toursarkissian B. Treatment of abdominal aortic aneurysms: the role of endovascular repair. AORN J. 2014;100(3):241–259.

14. Stather PW, Sidloff D, Dattani N, Choke E, Bown MJ, Sayers RD. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm. Br J Surg. 2013;100(7):863–872.

15. Hamdan A. Management of varicose veins and venous insufficiency. JAMA. 2012;308(24):2612–2621.

16. Hardman RL, Rochon PJ. Role of interventional radiologists in the management of lower extremity venous insufficiency. Semin Intervent Radiol. 2013;30(4):388–393.

17. Kheirelseid EAH, Crowe G, Sehgal R, et al. Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. J Vasc Surg Venous Lymphat Disord. 2018;6(2):256–270.

18. Pan Y, Zhao J, Mei J, Shao M, Zhang J. Comparison of endovenous laser ablation and high ligation and stripping for varicose vein treatment: a meta-analysis. Phlebology. 2014;29(2):109–119.

19. Poursaid A, Jensen MM, Huo E, Ghandehari H. Polymeric materials for embolic and chemoembolic applications. J Control Release. 2016;240:414–433.

20. Newsome J, Martin JG, Bercu Z, Shah J, Shekhani H, Peters G. Postpartum hemorrhage. Tech Vasc Interv Radiol. 2017;20(4):266–273.

21. Navuluri R, Kang L, Patel J, Van Ha T. Acute lower gastrointestinal bleeding. Semin Intervent Radiol. 2012;29(3):178–186.

22. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010;33(6):1088–1100.

23. Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 2017;23(4):307–317.

24. Ruiz Labarta FJ, Pintado Recarte MP, Alvarez Luque A, et al. Outcomes of pelvic arterial embolization in the management of postpartum haemorrhage: a case series study and systematic review. Eur J Obstet Gynecol Reprod Biol. 2016;206:12–21.

25. Li TF, Duan XH, Li Z, et al. Endovascular embolization for managing anastomotic bleeding after stapled digestive tract anastomosis. Acta Radiol. 2015;56(11):1368–1372.

26. Carrafiello G, Fontana F, Mangini M, et al. Endovascular treatment in emergency setting of acute arterial injuries after orthopedic surgery. Cardiovasc Intervent Radiol. 2012;35(3):537–543.

27. Akpinar E, Peynircioglu B, Turkbey B, Cil BE, Balkanci F. Endovascular management of life-threatening retroperitoneal bleeding. ANZ J Surg. 2008;78(8):683–687.

28. Ptohis ND, Charalampopoulos G, Abou Ali AN, et al. Contemporary role of embolization of solid organ and pelvic injuries in polytrauma patients. Front Surg. 2017;4:43.

29. Soro MP, Denys A, de Rham M, Baud D. Short and long term adverse outcomes after arterial embolisation for the treatment of postpartum haemorrhage: a systematic review. Eur Radiol. 2017;27(2):749–762.

30. Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG. 2008;115(10):1265–1272.

31. U.S. Building capacity to review and prevent maternal deaths. Report from nine maternal mortality review committees. http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed March 18, 2018.

32. Spreu A, Abgottspon F, Baumann MU, Kettenbach J, Surbek D. Efficacy of pelvic artery embolisation for severe postpartum hemorrhage. Arch Gynecol Obstet. 2017;296(6):1117–1124.

33. Doumouchtsis SK, Nikolopoulos K, Talaulikar V, Krishna A, Arulkumaran S. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG. 2014;121(4):382–388.

34. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100–107.

35. American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387–400.

36. Spies JS, Pelage JP. Uterine Artery Embolization and Gynecologic Embolotherapy. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2005:3–18.

37. Panagiotopoulou N, Nethra S, Karavolos S, Ahmad G, Karabis A, Burls A. Uterine-sparing minimally invasive interventions in women with uterine fibroids: a systematic review and indirect treatment comparison meta-analysis. Acta Obstet Gynecol Scand. 2014;93(9):858–867.

38. Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. . Cochrane Database Syst Rev. 2014;(12):CD005073.

39. Talaie R, Young SJ, Shrestha P, Flanagan SM, Rosenberg MS, Golzarian J. Image-guided treatment of varicoceles: a brief literature review and technical note. Semin Intervent Radiol. 2016;33(3):240–243.

40. Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian J Androl. 2016;18(2):234–238.

41. Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;10:CD000479.

42. Baldwin MJ, Moore HM, Rudarakanchana N, Gohel M, Davies AH. Post-thrombotic syndrome: a clinical review. J Thromb Haemost. 2013;11(5):795–805.

43. Lu Y, Chen L, Chen J, Tang T. Catheter-directed thrombolysis versus standard anticoagulation for acute lower extremity deep vein thrombosis: a meta-analysis of clinical trials. Clin Appl Thromb Hemost. 2018;24(7):1134–1143.

44. Shi Y, Shi W, Chen L, Gu J. A systematic review of ultrasound-accelerated catheter-directed thrombolysis in the treatment of deep vein thrombosis. J Thromb Thrombolysis. 2018;45(3):440–451.

45. Kakkar VV, Flanc C, Howe CT, O’Shea M, Flute PT. Treatment of deep vein thrombosis. A trial of heparin, streptokinase, and arvin. Br Med J. 1969;1(5647):806–810.

46. Watson L, Broderick C, Armon MP. Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev. 2016;11:CD002783.

47. Vedantham S, Goldhaber SZ, Julian JA, et al.; ATTRACT Trial Investigators. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med. 2017;377(23):2240–2252.

48. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report [published correction appears in Chest. 2016;150(4):988]. Chest. 2016;149(2):315–352.

49. Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 2009;20(11):1431–1440.

50. Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414–2421.

51. Bloomer TL, El-Hayek GE, McDaniel MC, et al. Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv. 2017;89(4):754–760.

52. Spencer FA, Bates SM, Goldberg RJ, et al. A population-based study of inferior vena cava filters in patients with acute venous thromboembolism. Arch Intern Med. 2010;170(16):1456–1462.

53. Ha CP, Rectenwald JE. Inferior vena cava filters: current indications, techniques, and recommendations. Surg Clin North Am. 2018;98(2):293–319.

54. Steinberger JD, Genshaft SJ. The role of inferior vena cava filters in pulmonary embolism. Tech Vasc Interv Radiol. 2017;20(3):197–205.

55. Bikdeli B, Chatterjee S, Desai NR, et al. Inferior vena cava filters to prevent pulmonary embolism: systematic review and meta-analysis. J Am Coll Cardiol. 2017;70(13):1587–1597.

56. Morales JP, Li X, Irony TZ, Ibrahim NG, Moynahan M, Cavanaugh KJ Jr. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2013;1(4):376–384.

57. Jaffe TA, Nelson RC. Image-guided percutaneous drainage: a review. Abdom Radiol (NY). 2016;41(4):629–636.

58. Harisinghani MG, Gervais DA, Maher MM, et al. Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases. Radiology. 2003;228(3):701–705.

59. Klein JS, Schultz S, Heffner JE. Interventional radiology of the chest: image-guided percutaneous drainage of pleural effusions, lung abscess, and pneumothorax. AJR Am J Roentgenol. 1995;164(3):581–588.

60. Arellano RS, Gervais DA, Mueller PR. Computed tomography-guided drainage of mediastinal abscesses: clinical experience with 23 patients. J Vasc Interv Radiol. 2011;22(5):673–677.

61. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2010; 50(12):1695]. Clin Infect Dis. 2010;50(2):133–164.

62. Wallace MJ, Chin KW, Fletcher TB, et al.; Society of Interventional Radiology. Quality improvement guidelines for percutaneous drainage/aspiration of abscess and fluid collections. J Vasc Interv Radiol. 2010;21(4):431–435.

63. Charles HW. Abscess drainage. Semin Intervent Radiol. 2012;29(4):325–336.

64. Burke LM, Bashir MR, Gardner CS, et al. Image-guided percutaneous drainage vs. surgical repair of gastrointestinal anastomotic leaks: is there a difference in hospital course or hospitalization cost? Abdom Imaging. 2015;40(5):1279–1284.

65. Clancy C, Boland T, Deasy J, McNamara D, Burke JP. A meta-analysis of percutaneous drainage versus surgery as the initial treatment of Crohn’s disease-related intra-abdominal abscess. J Crohns Colitis. 2016;10(2):202–208.

66. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1–133.

67. Tandon S, Shahab R, Benton JI, Ghosh SK, Sheard J, Jones TM. Fine-needle aspiration cytology in a regional head and neck cancer center: comparison with a systematic review and meta-analysis. Head Neck. 2008;30(9):1246–1252.

68. Novoa E, Gürtler N, Arnoux A, Kraft M. Role of ultrasound-guided core-needle biopsy in the assessment of head and neck lesions: a meta-analysis and systematic review of the literature. Head Neck. 2012;34(10):1497–1503.

69. Gupta S, Henningsen JA, Wallace MJ, et al. Percutaneous biopsy of head and neck lesions with CT guidance: various approaches and relevant anatomic and technical considerations. Radiographics. 2007;27(2):371–390.

70. Cunningham JD, McCusker MW, Power S, et al. Accessible or inaccessible? Diagnostic efficacy of CT-guided core biopsies of head and neck masses. Cardiovasc Intervent Radiol. 2015;38(2):422–429.

71. Wu EH, Chen YL, Wu YM, Huang YT, Wong HF, Ng SH. CT-guided core needle biopsy of deep suprahyoid head and neck lesions. Korean J Radiol. 2013;14(2):299–306.

72. Lipnik AJ, Brown DB. Image-guided percutaneous abdominal mass biopsy: technical and clinical considerations. Radiol Clin North Am. 2015;53(5):1049–1059.

73. Caoili EM, Davenport MS. Role of percutaneous needle biopsy for renal masses. Semin Intervent Radiol. 2014;31(1):20–26.

74. Zhan P, Zhu QQ, Miu YY, et al.; Lung Cancer Collaborative Group. Comparison between endobronchial ultrasound-guided transbronchial biopsy and CT-guided transthoracic lung biopsy for the diagnosis of peripheral lung cancer: a systematic review and meta-analysis. Transl Lung Cancer Res. 2017;6(1):23–34.

75. Metz T, Heider A, Vellody R, et al. Image-guided percutaneous core needle biopsy of soft-tissue masses in the pediatric population. Pediatr Radiol. 2016;46(8):1173–1178.

76. Odisio BC, Wallace MJ. Image-guided interventions in oncology. Surg Oncol Clin N Am. 2014;23(4):937–955.

77. Hage WD, Aboulafia AJ, Aboulafia DM. Incidence, location, and diagnostic evaluation of metastatic bone disease. Orthop Clin North Am. 2000;31(4):515–528.

78. Kaloostian PE, Yurter A, Zadnik PL, Sciubba DM, Gokaslan ZL. Current paradigms for metastatic spinal disease: an evidence-based review. Ann Surg Oncol. 2014;21(1):248–262.

79. Laredo JD, Chiras J, Kemel S, Taihi L, Hamze B. Vertebroplasty and interventional radiology procedures for bone metastases. Joint Bone Spine. 2018;85(2):191–199.

80. De la Garza-Ramos R, Benvenutti-Regato M, Caro-Osorio E. Vertebroplasty and kyphoplasty for cervical spine metastases: a systematic review and meta-analysis. Int J Spine Surg. 2016;10:7.

81. McCarthy J, Davis A. Diagnosis and management of vertebral compression fractures. Am Fam Physician. 2016;94(1):44–50.

82. Ma J, Gimenez JM, Sandow T, et al. Intraarterial liver-directed therapies: the role of interventional oncology. Ochsner J. 2017;17(4):412–416.

83. Majumdar A, Roccarina D, Thorburn D, Davidson BR, Tsochatzis E, Gurusamy KS. Management of people with early- or very early-stage hepatocellular carcinoma: an attempted network meta-analysis. Cochrane Database Syst Rev. 2017;(3):CD011650.

84. Han Y, Yan D, Xu F, Li X, Cai JQ. Radiofrequency ablation versus liver resection for colorectal cancer liver metastasis: an updated systemic review and meta-analysis. Chin Med J (Engl). 2016;129(24):2983–2990.

85. Gruber-Rouh T, Marko C, Thalhammer A, et al. Current strategies in interventional oncology of colorectal liver metastases. Br J Radiol. 2016:20151060

86. Loveman E, Jones J, Clegg AJ, et al. The clinical effectiveness of ablative therapies in the management of liver metastases: systematic review and economic evaluation. Health Technol Assess. 2014;18(7):vii–viii, 1–283.

87. Ray CE Jr. Interventional radiology in cancer patients. Am Fam Physician. 2000;62(1):95–102.

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Jul 1, 2020

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article