Endoscopic ultrasound (EUS) has transitioned from a primarily diagnostic to a therapeutic procedure. EUS-guided drainage of intra-abdominal fluid collections is common practice with vast data in the management of symptomatic, mature pancreatic fluid collections. Evidence has demonstrated that EUS-guided drainage for these intra-abdominal fluid collections is effective with an acceptable safety profile. These techniques are being utilized for the management of other intra-abdominal fluid collections with equally positive results. This review will discuss the utilization of EUS for the management of various intra-abdominal fluid collections, discussing efficacy, safety, and limitations.

Interventional radiology plays a vital role in performing noninvasive, nonvascular genitourinary interventions. This article discusses practical aspects of the biopsy technique using the cortical tangential approach for native and transplant kidneys. Additionally, the indications, contraindications, and procedure details of the nephrostomy tube and nephroureteral placement will be reviewed.

Percutaneous biopsy and drainage of pancreatic lesions, though less frequent due to advancements in endoscopic techniques, remain vital skills for interventional radiologists. This review details the indications, options, approaches, and technical considerations for pancreatic biopsy and (peri)pancreatic fluid drainage by examining a comprehensive range of literature. The importance of a multidisciplinary approach is emphasized to ensure optimal patient care and outcomes, highlighting current best practices and recent advancements.

This article explores various techniques and tips for performing successful percutaneous biopsies of the breast and axillary lymph nodes using different imaging modalities. The discussion includes detailed image guidance on ultrasound-guided, stereotactic/tomosynthesis-guided, and MRI-guided biopsies. Advice for draining fluid collections in the breast is also reviewed. Key findings include the comparative effectiveness of different imaging techniques and practical advice for improving procedural outcomes. This information is particularly relevant for radiologists involved in diagnostic and interventional breast care. Recommendations for optimizing biopsy procedures and managing complications are also presented.

When consulted for percutaneous catheter drainage (PCD) of abdominopelvic collections, interventional radiologists (IRs) should consider the appropriateness of this technique in the context of other options such as conservative, endoscopic, or surgical management. Whenever possible, published data should be considered prior to performing percutaneous drainage, especially as regards controversial scenarios such as the use of fibrinolytic therapy, the primary placement of large-bore drainage catheters, the drainage of cystic tumors, the drainage of splenic abscesses, and the treatment of collections lacking an in-line drainage window. This article examines past and present published data on PCD to dispel some common myths and guide IRs toward the best applications of PCD.

Percutaneous cholecystostomy (PC) is a recognized treatment option for the management of acute cholecystitis and is an integral component of the treatment algorithm in the 2018 Tokyo Guidelines. The utilization of PC has significantly increased over the past 30 years, particularly in the setting of critically ill patients and those with extensive comorbidities who are poor surgical candidates. The indications, complications, patient selection considerations, and technical complexities of the procedure will be discussed. Postprocedural drain management and the potential for shortened indwelling time are reviewed.

Liver biopsy is a crucial aspect of interventional radiology and plays a significant role in the management of hepatobiliary diseases. Radiologists commonly perform two major image-guided liver biopsy techniques: percutaneous and transjugular approaches. It is essential for radiologists to understand the role of liver biopsy in diagnosing and treating hepatobiliary conditions, the procedural details involved, and how to manage potential complications. This article reviews the indications, contraindications, techniques, and efficacy of image-guided liver biopsy, with a focus on both percutaneous and transjugular methods.

Thyroid nodules are prevalent, estimated to affect up to 68% of the population, and the incidence increases with age. With the advances in medical imaging utilization, the detection of incidental thyroid nodules continues to rise, and given the low rate of malignancy in incidentally discovered thyroid nodules (4-15%), diagnostic guidelines are imperative for their management. Several guidelines have been developed: the most commonly used guidelines in the United States include the American Thyroid Association (ATA) Guidelines and the American College of Radiology Thyroid Imaging Reporting Data System (TI-RADS). These guidelines call for the utilization of a biopsy of nodules depending on a sonographic morphologic categorization. This article aims to briefly review these two main guidelines and discuss the techniques for ultrasound-guided biopsy of thyroid nodules.

Computed tomography guidance enables deep neck biopsies beyond the range of ultrasound and spares the patient more invasive open surgery. This review article describes proper patient preparation, devices, and techniques. Cases illustrate the favored access routes in the suprahyoid neck including the subzygomatic, retromandibular, transfacial, submastoid, transoral, and posterior approaches, as well as in the infrahyoid neck including the anterolateral and posterolateral approaches. A thorough understanding of the neck anatomy, assessment of prior imaging with respect to eloquent structures such as arteries and nerves, and a sound knowledge of the technique will result in an extremely low complication rate.

Percutaneous image-guided needle biopsies are a safe and minimally invasive method of obtaining tissue of bone lesions. Radiologists are an integral part of a multidisciplinary team (MDT) approach to patient care in obtaining tissue for both pathologic diagnosis and advanced genetic/molecular testing. By utilizing image guidance, radiologists can target bone lesions with a very low complication rate. This review will discuss our approach to image-guided biopsies of bone lesions. Radiologists should be familiar with patient selection and imaging workup prior to performing biopsies, as well as the importance of coordinating the biopsy approach and sampling with the patient's clinical team. Management of bleeding and thrombotic risk in patients undergoing bone biopsies is also an important preprocedural consideration and will be discussed. The majority of bone biopsies are performed utilizing moderate sedation for patient analgesia and comfort, but close attention should be paid to patient comorbidities and potential interacting medications. Although computed tomography guidance remains the mainstay of image-guided biopsy, there are some circumstances in which ultrasound or fluoroscopic guidance may be beneficial. New advances in powered drill technology have made tissue sampling of bone lesions particularly sclerotic bone lesions both safer and faster with increased tissue yield. Finally, we will discuss image-guided biopsy of difficult anatomic regions that require special techniques to yield tissue safely.

Venous malformations (VMs) represent the most common type of congenital vascular anomalies, characterized by slow-flow lesions arising from disorganized angiogenesis. These malformations can vary widely in size, location, and clinical impact, presenting significant challenges in diagnosis and management. A multidisciplinary approach is essential for optimizing care, with goals centered on symptom relief and functional preservation. Diagnostic evaluation typically involves clinical examination, imaging, and, in complex cases, genetic testing. Interventional radiology, particularly sclerotherapy and endovascular embolization, has become the first-line treatment, complemented by surgical and emerging molecular therapies, particularly targeting the mTOR/PI3K/AKT pathway. This review provides a comprehensive examination of the genetics, clinical presentation, and key diagnostic imaging aspects of VMs, along with a detailed discussion of current treatment modalities, emerging therapeutic techniques, and future directions for improving patient care.

Lymphatic malformations (LMs) arise from errors in lymphatic vascular development during embryogenesis and encompass an array of conditions that span from common cystic LMs to complex lymphatic anomalies (CLAs). Manifestations of LMs are wide-ranging, from clinically inconsequential to life-threatening. Proper diagnosis and management can be challenging and often benefit from an experienced multidisciplinary team. Cystic LMs are localized entities for which percutaneous sclerotherapy is the mainstay treatment. CLAs, on the other hand, are more diffuse in involvement and typically require multimodal therapy. With advances in the genetic understanding of LMs, targeted systemic therapies have been increasingly utilized with promising results. Thoracic duct interventions, both surgical and percutaneous, have a limited role in CLAs and should be approached cautiously to avoid significant complications. In this review, we discuss the genetic basis, imaging findings, and management options for LMs, with a particular focus on relevant interventional radiology techniques.

High-flow arteriovenous malformations (AVMs) are among the rarest and most recalcitrant lesions in medicine. Patients with these anomalies are best managed longitudinally in tertiary referral centers by dedicated multidisciplinary teams that include surgeons, dermatologists, hematologists, geneticists, and interventional radiologists. A significant percentage of these lesions cannot be cured per se and intervention can worsen symptoms or preclude effective future embolization. Existing classification systems help guide treatment, but in nearly all cases, therapy must be individualized based on patient, symptoms, and lesion angioarchitecture. For various reasons, referral to tertiary centers may be impossible for some patients. The purpose of this article is to provide an approach to the evaluation and treatment of these abnormalities.

Historically, the care for patients with vascular anomalies has been challenging due to the complex nature and diversity of these anomalies with a wide array of symptomatology. In the recent past, most therapies for vascular anomalies focused on surgical, procedural, and supportive care measures to treat local symptoms, but many patients still experienced significant disease with excess morbidity and mortality. Today, the pharmacotherapeutic options available for treating vascular anomalies have greatly expanded due to the increased understanding of the genetic and molecular pathways causing these anomalies, with the subsequent development of more targeted pharmacotherapies. In addition to the growth in targeted medications available to treat patients with vascular anomalies, there has been an improved understanding of the hematologic abnormalities related to these diseases and how to manage them. While interventional radiologists do not typically primarily manage systemic medications to treat vascular anomalies, a baseline understanding of the medical management of these diseases is essential to ensuring that a contemporary, multidisciplinary, multimodal approach to treatment is pursued when appropriate. Ultimately, patients are now benefitting from having multiple modalities of treatments available to them and are experiencing improved quality of life and less morbidity.

Vascular malformations (VMs) are a heterogeneous group of arterial, venous, capillary, and/or lymphatic networks that typically are present at birth and grow with the patient. Signs and symptoms associated with VM range from absent to severe, with a broad spectrum of pain, cosmetic disfigurement, and local tissue destruction. Treatment options for these malformations extend from observation to surgical reconstruction. Each treatment modality has a role in the management of vascular anomalies, but also has specific challenges. Observation is not always sufficient, medical therapies may only be available for a subset of patients and are ultimately not curative, and surgical excision may itself be disfiguring or incomplete/not definitive. Sclerotherapy and/or embolotherapy have become a cornerstone of treatment for many types of VMs. These techniques are applicable to a wide range of VMs, are less invasive, have a shorter recovery period, and are repeatable. Although some VMs may not be amenable to percutaneous or endovascular treatment given their location, and multiple sessions may be required for select large and complex VMs, these minimally invasive treatments are often first line and may be definitive in treating VMs. Various agents may be used in sclerotherapy and embolotherapy, each with their own risks and benefits. Although there is a paucity of Level 1 evidence supporting the superiority of one agent over another, longstanding case series and expert experience exist, informing our knowledge of the safety and efficacy of sclerotherapy and embolotherapy. A brief overview of the most used sclerotherapy and embolotherapy agents and their uses is provided.

Vascular anomalies (VAs) are a group of rare diseases affecting 0.01 to 0.02% of the population. VA may be associated with complex disorders affecting multiple organ systems, requiring a multidisciplinary approach to treatment. Multidisciplinary clinics are most frequently affiliated with pediatric centers. Multidisciplinary clinics in the adult setting are rare. Many adult VA patients find it difficult to establish care with individual providers, let alone a multidisciplinary clinic, leading to barriers to lifelong comprehensive care.

Vascular anomalies (VAs) are a heterogeneous group of vascular malformations and tumors that are frequently encountered in daily practice. While most are benign, malignant vascular tumors exist, as do other nonvascular soft-tissue malignancies that may masquerade as a benign VA. The subtleties of arriving at an accurate diagnosis can be intimidating, as new entities are described and names of conditions have been modified. Therefore, the goal of this article is to describe the classic imaging findings of VAs so that the interventional radiologist can confidently and competently contribute to management decisions, with special attention to ominous imaging features that should prompt biopsy or further imaging workup.