This includes the so-called intermittent claudication (peripheral arterial disease = PAD), which can be treated minimally invasively and gently by balloon dilatation and inserting metallic vascular endoprostheses (stents) in narrowed or blocked calcified pelvic and leg arteries.

Another important area of application for interventional radiology is the treatment of a carotid artery stenosis by stents or acutely occluded cerebral arteries (acute stroke) with dedicated tiny catheters and stents (so-called stent retrievers) introduced via the groin artery by aspiration and removal of the clot (mechanical embolectomy). This novel, minimally invasive treatment option has revolutionized acute stroke therapy and in many instances leads to restoration of neurological functions.

Stenotic or occluded visceral arteries (renal arteries, intestinal arteries or hepatic arteries) and arm arteries (subclavian artery with subclavian steal syndrome) can also be effectively treated for symptoms with balloon expansion and stents.

In the case of life-threatening enlargements of arteries (aneurysms), in particular of the main artery (aortic aneurysm), the risk of rupture can be eliminated by inserting coated endoprostheses (so-called stentgrafts) via the groin arteries.

The treatment of so-called arteriovenous vascular malformations (AVM) and fistulas is often successfully managed by releasing coagulants locally to close vascular wall bulges.

Embolization of acute hemorrhage is a minimally invasiive and effective treatment for life-threatening bleeding sources from internal organs, mostly caused by tumors or after surgical or interventional procedures. The bleeding site is quickly identified using small tubes (catheters) and blocked with the help of metallic coils or small beads.

Even in large body veins, constrictions and occlusions can lead to malfunctions and/or symptoms of congestion. These include pelvic veins, the lower and upper vena cava and efferent arm veins in dialysis shunts. As in the arteries, these diseases can be treated minimally invasively with balloons and vascular stents.

In deep venous thrombosis, an umbrella-like tool (cava filter) can be inserted into the inferior vena cava to effectively prevent parts of detached blood clots from the lower extremities reaching the pulmonary circulation or the brain.

A successful field of application of interventional radiology is the treatment of dilated veins of the testicles (in men) or the ovarian veins (in women). As with varicose veins in the legs, the veins are massively enlarged due to leaking orifice valves of the testicular veins or ovarian veins with congestion / reversal of blood flow. In men, this leads to varicoceles in the testicles that impair fertility, and in women to diffuse pelvic pain that often remains undetected for years (so-called “pelvic congestion syndrome”). The interventional radiologist can advance a small catheter into these dilated veins via the groin veins and seal them with small coils and releasing coagulants. These highly effective procedures are called sclerotherapy.

In the context of fatty liver or cirrhosis of the liver, high pressure often develops in the venous system draining the bowels (portal vein), which leads to ascites within the abdomen and development of backup varicose veins in particular in the esophagus wall, which tend to bleed. Here, the insertion of a metallic tube bridging the liver tissue between the portal vein and the liver veins has proven to decrease portal pressure (so-called TIPS = "transjugular portosystemic shunt"). These tubes are inserted through the jugular vein with small catheters.

Benign tumors

Uterine fibroids are one of the most common benign tumors in women of childbearing age. In two thirds of the cases, there are more than one fibroid in the uterus. A US screening ultrasound found nearly 70% of white and 80% of black women in their 50s had fibroids. For 40-year-old women, it was already estimated 53%. Although these tumors are not life-threatening, they can severely impact quality of life.

Based on the symptoms, the gynecologist determines the extent of the disease using an ultrasound examination; number, size and location of the fibroids. The supplementary magnetic resonance imaging (MRI) often allows an improved and precise assessment of the pelvic anatomy and diagnosis of additional diseases of the uterine wall such as adenomyosis (internal endometriosis). In addition to the fibroid-related symptoms (e.g. heavy and prolonged menstrual bleeding, iron deficiency anemia, pain, urinary frequency, constipation, pelvic pressure), the patient’s life also influences the choice of treatment. This includes whether surgery (e.g. previous caesarean section or fibroid resection) have already been carried out, whether family planning has already been completed or when the menopause is to be expected. After all the basic determinants have been incorporated into the treatment decision, the advantages and disadvantages of the various treatment options are explained. In principle, a decision can be made between conservative, minimally invasive and invasive procedures. If conservative treatments (e.g. medication, hormones) are not sufficient, the least invasive therapy should be offered; especially if the patient refuses surgery including abdominal incision.

The minimally invasive treatment options include, in addition to surgical hysteroscopy, laparoscopic fibroid enucleation, or da Vinci robotically assisted fibroid surgery, the embolization of the uterine arteries ("fibroid embolization"), which has been used by radiologists for over 30 years. A tiny tube (catheter) is inserted into the groin artery under local anesthesia. After probing the uterine arteries, small beads are slowly injected through the tube until the fibroid arteries are occluded, thus starving the fibroids.

The scientifically proven advantages of organ-preserving fibroid embolization are:

• no abdominal incision
• no anesthesia
• complete elimination of all fibroids and possibly also adenomyosis
• short duration of the procedure (30 - 60 minutes) and hospital stay (2 - 4 days)
• rapid recovery with possible return to work after discharge from the hospital

If family planning is uncompleted, fibroid embolization can be considered if gynecological measures fail. Fibroid embolization is usually painful for 1 day; the intensity of the abdominal pain can be significantly reduced by the use of dedicated pain therapy. In a detailed consultation, the interventional radiologist can critically explain the advantages and disadvantages of the various treatment options, especially fibroid embolization, and thus may support the patient in her choice of therapy.

The (benign) enlargement of the prostate (benign prostatic hyperplasia = BPH) is one of the most common illnesses amongst men leading to lower urinary tract symptoms (LUTS). The average rate of BPH exceeds 50% of men over 60 years old and it is positively correlated with age. Interventional radiology offers minimally invasive prostate embolization (PAE) for symptoms that cannot be alleviated with medication. Similar to fibroids, prostate embolization is a minimally invasive therapy, does not require general anesthesia and is associated with a short hospital stay. Under local anesthesia, a thin tube (catheter) is inserted into the artery of the prostate gland via the groin artery, and tiny beads are slowly injected until the central parts of the arteries are occluded. In the medium term, embolization causes the prostate gland to shrink. A noticeable improvement in the patient's symptoms often occurs shortly after the embolization.

Malignant tumors

Chemoembolization of malignant liver tumors (TACE)

Various forms of therapy are available for the treatment of liver cancer (hepatocellular carcinoma) and liver metastases (e.g. in colon cancer or uveal melanoma). In addition to surgical excision, other local ablation modalities (heating by radio frequency or microwaves or cooling by kryoablation) are available.

Various drugs can also be used systemically as chemotherapy, but also locally via the hepatic arteries such as transarterial chemotherapy (TACE). Compared to other organs, the liver has a dual blood supply. Normal liver tissue receives 75% of its perfusion from the intestinal vein system (portal vein) and only 25% from the hepatic artery. In contrast, malignant liver tumors are predominantly (up to 95%) supplied via the hepatic arteries. By cutting off these tumors from the blood suppy with the use of chemotherapeutic agents, cell death in the tumor is achieved, while the healthy liver tissue continues to be supplied with blood via the portal vein. The advantages of chemoembolization are the low burden for the patient, low-complication use with a good quality of life, significantly shorter hospital stays and a reduction in the volume of the tumor. The choice of therapy, the combination of the individual methods and the time at which the therapy begins are only standardized for liver cancer and are adapted to the overall situation of the patients in a tumor board.

Percutaneous tumor ablation: CT-controlled tumors, especially in the liver and kidneys, can be destroyed effectively and minimally invasively with heat (radio frequency or microwave ablation) or cold (cryoablation) via thin probes inserted through the skin. Each procedure has certain advantages and disadvantages, and the choice ultimately depends on the size, number, exact location and type of tumor, among other things.

CT-guided pain therapy

Back pain is considered the common disease par excellence. Women are affected slightly more often than men. About 33% of people suffer from back pain every year, and 84% over their lifetime. The herniated disc is one of the most common causes of acute low back pain and/or radiating pain. The natural course of a symptomatic herniated disc is favorable with an improvement in pain within 6-12 weeks in 80% of patients. However, relieving pain and disability during this time is essential. The standard therapy for pain management due to a herniated disc is conservative (rest, medication, physical therapy, etc.). Though various pain management strategies are available as part of a multimodal approach, they are often incompletely effective and accompanied by side effects. If conservative treatment fails, disc surgery is often considered. However, the results of surgical treatment are suboptimal and carry a substantial risk of complications and failed back surgery syndrome.

According to guidelines, diagnostic infiltrations (using local anesthetics) and therapeutic infiltrations with steroids are the most common minimally invasive techniques. These can be injected precisely at the site of pain with thin needles using X-ray fluoroscopy and/or CT. The established procedures for the treatment of the epidural space and the nerve roots include "periradicular" or "transforaminal infiltration", as well as interlaminar infiltration and sacral blockage. Targeted intraarticular or periarticular infiltration of the joints with corticosteroids/local anesthetics has proven effective in the case of pseudoradicular pain, the so-called facet syndrome (e.g. as part of an inflammation of the small vertebral joints). As a symptomatic and less causal alternative, in the case of a positive diagnostic/therapeutic facet joint blockage and persistent symptoms, a permanent disruption of the small capsular nerves of the vertebral joints with cold (cryodenervation) or heat (thermocoagulation) introduced via probes can be offered.

Over the past few decades, many alternative minimally invasive disc procedures have been developed to reduce the need for surgery. Currently, surgery is limited to treating patients with progressive neurological deficit (paralysis), cauda equina syndrome, and severe excruciating pain. Minimally invasive techniques include but are not limited to percutaneous mechanical, laser, or radiofrequency coblation (nucleoplasty), disc decompression, and chemonucleolysis using an oxygen-ozone mixture (so-called ozone nucleolysis = ONL).

A tiny needle is inserted into the core of the intervertebral disc with image control (CT and/or X-ray fluoroscopy) under local anesthesia, then an ozone-oxygen mixture is slowly injected. When the needle is withdrawn, additional cortisone and local anesthesia are injected around the nerve root. The inexpensive ozone injection has a very high clincal success rate (pain free in 70 - 80% within the next 6 months) with a very low complication rate (less than 0.1%) and is recommended by the Austrian Ludwig Boltzmann Institute as the only minimally invasive, scientifically proven procedure in the treatment of intervertebral disc disease. We introduced and further developed this modality in Austria. In the last 20 years, over 20,000 painful herniated discs/protrusions could be successfully treated during a one-day in hospital stay.

For more information about the ozone disc treatment please visit the short video clip: Ozone nucleolysis

Cement augmentation of vertebral or sacral fractures (vertebroplasty, kyphoplasty, sacroplasty)

Pain reduction and stabilization are of primary importance with acute osteoporotic vertebral compression fractures. Although many patients heal with conservative treatment consisting of bed rest or activity modification, analgesics, and bracing, the management of severe pain compels some patients to seek vertebroplasty or kyphoplasty in order to restore the stability of the injured vertebrae and relieve low back pain. The cement (PMMA) is injected into a fractured vertebral body through one or two bone biopsy needles. The cement is directly injected into the fractured vertebra without creation of a void unlike in balloon kyphoplasty.The "cement", a viscous paste, hardens in minutes and seals the fracture points. As a result, the affected vertebra stabilized immediately Most patients are quickly free of pain. In patients with osteoporosis, a broken bone, especially in the spine or sacrum, can happen again at any time and can be treated with minimally invasive cement augmentation.