Aortic aneurysm and dissections are potentially life threatening conditions. The advent of endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) has reduced perioperative mortality and morbidity and are now established therapy methods for treatment of aortic disease. Adequate pre- and intraoperative imaging is important for optimal results in endovascular procedures. However, the standard use of CT and angiography may not always be sufficient to provide necessary information required for treatment, and complementary techniques are warranted in selected cases. TEVAR in acute complicated type B aortic dissections is proven effective in several reports, but long-term clinical outcome and aortic remodelling are still not fully evaluated. Intravascular phased array imaging (IPAI) was used in patients undergoing EVAR and TEVAR for aortic aneurysm and dissection. The combined information from IPAI and fluoroscopy allowed exact positioning of the stent graft. The colour Doppler function facilitated detection of blood-flow in relevant arteries during and after the procedures, and it also facilitated control of ceased flow in excluded false lumens or aneurysms. Clinical early and long-term results after TEVAR for acute complicated type B aortic dissection were investigated in all patients treated between 1999 and 2009 at UppsalaUniversityHospital. Results were favourable regarding survival and permanent neurological complications. Long-term follow-up of aortic morphological changes in the same patient group showed overall significant reduction of aortic and false lumen diameters, and an increase of true lumen diameter. Total thrombosis of the false lumen occured more often in patients with DeBakey IIIa aortic dissection, than in IIIb. In conclusion, IPAI may be a complementary tool to traditional imaging modalities in EVAR and TEVAR in selected cases. Long-term clinical outcome is excellent with favourable aortic remodeling after TEVAR in patients with acute complicated type B aortic dissection.

Aortic stenosis is the most common acquired heart valve condition. Open-heart surgical aortic valve replacement is an effective treatment for patients who receive it. However, approximately one-third of patients who require this treatment do not receive it due to the risks associated with the surgery. Percutaneous aortic valve replacement (PAVR) is a minimally invasive technique that can replace the aortic valve of patients contraindicated for open-heart surgery. Although PAVR is now entering clinical practice, a closed bore hybrid x-ray/MRI (CBXMR) imaging system is under development to improve the safety and efficacy of PAVR. This system will harness the complementary strengths of x-ray imaging (surgical tool/vascular imaging) and MRI (cardiac soft tissue contrast) to deploy a bioprosthesis in the aortic annulus. An x-ray C-arm will be placed about 1 m from the entrance of the MRI scanner to facilitate smooth intermodality patient transfer during the procedure. The performance of a rotating-anode x-ray tube in the magnetic fringe field of a 1.5 T MRI scanner was investigated. A rotating-anode x-ray tube provides the fluoroscopy and angiography needed for PAVR. The magnetic fringe field can affect the ability of the x-ray tube to dissipate heat. It was shown that the fringe field perpendicular to the anode rotation axis can reduce anode rotation frequency. These effects can limit the maximum permissible power that can be safely dissipated on the anode track during a single exposure. In the fringe field strengths at the C-arm position (4-5 mT), anode rotation frequency only decreased by about 1%, which will have negligible impact on tube heat loadability. The fringe field can cause a field of view shift. The field of view shifted by approximately 3 mm, which can be corrected by active magnetic shielding and further collimation. An active magnetic shielding system was constructed that can correct focal spot deflection. These results are facilitating the construction of a prototype CBXMR system, the goal of which is to improve success rates for PAVR procedures.

Aortic stenosis is the most common acquired heart valve condition. Open-heart surgical aortic valve replacement is an effective treatment for patients who receive it. However, approximately one-third of patients who require this treatment do not receive it due to the risks associated with the surgery. Percutaneous aortic valve replacement (PAVR) is a minimally invasive technique that can replace the aortic valve of patients contraindicated for open-heart surgery. Although PAVR is now entering clinical practice, a closed bore hybrid x-ray/MRI (CBXMR) imaging system is under development to improve the safety and efficacy of PAVR. This system will harness the complementary strengths of x-ray imaging (surgical tool/vascular imaging) and MRI (cardiac soft tissue contrast) to deploy a bioprosthesis in the aortic annulus. An x-ray C-arm will be placed about 1 m from the entrance of the MRI scanner to facilitate smooth intermodality patient transfer during the procedure. The performance of a rotating-anode x-ray tube in the magnetic fringe field of a 1.5 T MRI scanner was investigated. A rotating-anode x-ray tube provides the fluoroscopy and angiography needed for PAVR. The magnetic fringe field can affect the ability of the x-ray tube to dissipate heat. It was shown that the fringe field perpendicular to the anode rotation axis can reduce anode rotation frequency. These effects can limit the maximum permissible power that can be safely dissipated on the anode track during a single exposure. In the fringe field strengths at the C-arm position (4-5 mT), anode rotation frequency only decreased by about 1%, which will have negligible impact on tube heat loadability. The fringe field can cause a field of view shift. The field of view shifted by approximately 3 mm, which can be corrected by active magnetic shielding and further collimation. An active magnetic shielding system was constructed that can correct focal spot deflection. These results are facilitating the construction of a prototype CBXMR system, the goal of which is to improve success rates for PAVR procedures.

Initiée dans les années 1960, la radiologie interventionnelle comprend les actes médicaux invasifs ayant pour but le traitement ou le diagnostic d’une pathologie réalisés sous guidage ou sous contrôle d’un moyen d’imagerie. L’enjeu de la thèse est de développer l’analyse sociohistorique de l’émergence d’une spécialité médicale – la radiologie interventionnelle – et d’en étudier les stratégies de légitimation. Trois axes d’investigation interdépendants sont plus particulièrement privilégiés. Le premier d’entre eux vise à comprendre comment est née cette pratique médicale en établissant l’archéologie des innovations dont elle résulte. Dans le deuxième, il s’agit d’analyser les stratégies de valorisation et les modes de faire-valoir de la radiologie interventionnelle. Les velléités d’autonomisation des radiologues interventionnels les ont ainsi conduits à mobiliser différents registres de légitimité (légitimité scientifique, légitimité professionnelle dans le champ médical, légitimité régulatoire). Le troisième axe permet quant à lui la prise en compte de la question de la démarcation sociale et des frontières. Étant porteuse d’une transgression de la dichotomie établie entre sphères diagnostique et thérapeutique, la radiologie interventionnelle a de fait entraîné une reconfiguration des relations entre spécialités. L’investigation s’appuie sur une méthodologie plurielle combinant entretiens semidirectifs, observations in situ (bloc opératoire, scanner, réunions de concertation pluridisciplinaire, consultations) et exploitation de données scientométriques. Une mise en perspective internationale avec la situation canadienne permet d’étudier l’impact des contextes nationaux sur la diffusion et la reconnaissance de la radiologie interventionnelle. / Introduced in the 1960s, interventional radiology includes invasive medical procedures for the treatment or diagnosis of a pathology performed under the guidance or control of an imaging device. The aim of the thesis is to develop the sociohistorical analysis of the emergence of a medical specialty – interventional radiology – and to study its legitimization strategies. Three interdependent lines of inquiry are privileged in particular. The first aims to understand how this medical practice was born by establishing the archaeology of the innovations that gave rise to it. In the second, it is a question of analyzing the strategies of valorization and the ways of valuing interventional radiology. The interventional radiologists’ desire for independence has led them to mobilize different registers of legitimacy (scientific legitimacy, professional legitimacy in the medical field, regulatory legitimacy). The third line of inquiry allows for the issue of social demarcation and boundaries to be taken into account. As it is a means of transgressing the established dichotomy between the diagnostic and therapeutic spheres, interventional radiology has in fact led to a reconfiguration of the relations between specialties. The investigation is based on a methodology combining semi-directive interviews, in situ observations (operating theater, multidisciplinary consultation meetings, consultations) and the use of scientometric data. An international perspective on the Canadian situation makes it possible to study the impact of national contexts on the dissemination and recognition of interventional radiology.

As fístulas arteriovenosas da região do seio cavernoso constituem as fístulas carotidocavernosas que podem ser diretas ou indiretas. As indiretas são raras, a sua sintomatologia é variada e o tratamento é controverso. Este estudo compreendeu a análise prospectiva de 44 pacientes portadores de fístulas carotidocavernosas indiretas (FCCI) no período de 01 de janeiro de 1994 e 31 de janeiro de 2004, 42 com etiologia espontânea e dois pacientes com etiologia traumática, sendo estes analisados separadamente. Doze (12) pacientes foram submetidos à conduta expectante e orientados a realizar manobras de compressão carótido-jugular. O tratamento endovascular foi realizado por via arterial, venosa ou combinação dos dois, num total de 30 pacientes. Considerando o grupo inteiro, ocorreu trombose espontânea em aproximadamente 24% dos pacientes. Os sintomas e o aspecto angiográfico após o tratamento evoluíram com melhora ou cura em 100% dos casos, com oclusão completa das FCCI em 63,3%, a grande maioria destes submetidos a apenas um procedimento. Além dos acessos venosos tradicionais aos seios cavernosos, vias de acesso alternativas através da veia oftálmica superior foram realizadas por punção percutânea de veia facial, veia supratroclear ou veia frontal. O material embolizante mais utilizado foi o adesivo tissular líquido, \"cola\", isoladamente ou em conjunto com outros materiais. Houve complicações transitórias em 13,3% dos pacientes tratados e nenhuma complicação permanente foi observada, o que demonstrou a baixa morbidade deste procedimento / The arteriovenous fistulas of the cavernous sinus (CS) region constitute the carotid-cavernous fistula, which can be direct or indirect. The indirect type is quite rare, its clinical features is very inespecific and its treatment modalities controversial. Forty-four patients with indirect carotid-cavernous fistulas (ICCF) were studied in a prospective manner between January 1994 to January 2004, 42 with spontaneous etiology and 2 with traumatic etiology, being these analyzed separately. Twelve (12) patients were submitted to a expectant management and instructed to perform carotid-jugular compression. Endovascular treatment was accomplished by arterial approach, vein approach or combination of both, in a total of 30 patients. Considering the entire group, spontaneous thrombosis was observed in approximately 24%. Symptoms and the angiographic features after endovascular treatment improved or disappeared in 100% of the cases, with total obliteration in 63.3%, most of them submitted to just one procedure. Despite the traditional venous routes to the CS, alternative accesses through the superior ophthalmic vein (SOV) were accomplished by percutaneous puncture of the facial, supratrochlear or frontal vein. Liquid adhesive (glue) was the most often embolic material used isolated or with other materials. No permanent complication was observed and only 13,3% of the patients treated cursed with transitory complications, what demonstrated the low morbidity of this procedure

Introdução: Os stents farmacológicos (SF) de primeira geração surgiram com o intuito de reduzir as taxas de reestenose intra-stent e de revascularização da lesão-alvo, sendo mais eficazes quando comparados aos stents não-farmacológicos (SNF), porém com aumento de risco de trombose do stent (TS) muito tardia. A cobertura tecidual incompleta e a má aposição tardia das hastes dos stents podem estar vinculadas à TS. O SF de segunda geração BioMatrix®, que utiliza um polímero bioabsorvível, surgiu na expectativa de redução da TS. Devido à alta acurácia e reprodutibilidade e à análise precisa da cobertura tecidual e da aposição das hastes dos stents, a tomografia de coerência óptica (TCO) vem se tornando um método útil na análise desses aspectos. O objetivo desse estudo foi avaliar a cobertura tecidual e a aposição das hastes do SF BioMatrix® após longo período do implante. Métodos: Vinte pacientes submetidos ao implante do SF BioMatrix® (n = 15) ou do SNF S-Stent® (n = 5) foram acompanhados por um período mínimo de cinco anos e avaliados por meio da angiografia coronária quantitativa (ACQ), da ultrassonografia intracoronária (USIC) e da TCO. Para a análise estatística, foram utilizados os programas SPSS® versão 16.0 e SAS versão 9.2. O valor de p < 0,05 era considerado estatisticamente significante. As variáveis categóricas foram expressas em números absolutos e porcentuais e comparadas pelo teste exato de Fisher. As variáveis contínuas foram expressas em média e desvio padrão e/ou mediana e intervalo interquartílico e foram comparadas pelo teste não paramétrico de Mann-Whitney. Resultados: A ACQ demonstrou diferença, porém não significativa na perda tardia da luz entre o SF BioMatrix® e o S-Stent® [0,40 (0,21; 0,77) mm vs 0,68 (0,66; 0,82) mm, p = 0,205]. Os pacientes tratados com o SF BioMatrix® apresentaram porcentual de obstrução do stent significativamente menor quando comparados àqueles que receberam o S-Stent® [5,6 (4,4; 9,7)% vs 28,6 (24,7; 29,0)%, p =0,001]. A análise da TCO demonstrou 126 (8,7%) hastes não cobertas nos stents BioMatrix® e 23 (4,0%) nos S-Stents® (p = 0,297), estando a maioria delas bem apostas (117/126 e 21/23, respectivamente, p = 0,292). Apenas nove (0,6%) hastes nos SF e duas (0,4%) hastes nos SNF estavam simultaneamente sem cobertura tecidual e mal apostas (p = 0,924). No grupo BioMatrix®, apenas 1 (11,1%) paciente teve todas as hastes cobertas. Já no grupo S-Stent, 66,7% dos pacientes (2/3) apresentaram cobertura completa das hastes (p = 0,127). Conclusões: A avaliação tardia do SF BioMatrix® pela TCO mostrou cobertura tecidual e aposição em quase a totalidade de suas hastes, de maneira similar àquela encontrada nos SNF S-Stents®. / Introduction: First generation drug-eluting stents (DES) have emerged as a strategy to prevent in-stent restenosis and the need of target-vessel revascularization when compared to bare metal stents (BMS); but at the expense of a higher risk of very late stent thrombosis (ST). Uncovered and malapposed struts may be associated with both late and very late ST. It has been postulated that the second generation DES, the biolimus-eluting stent BioMatrixTM with biodegradable polymer, may reduce the incidence of ST. Given its high accuracy and reproducibility with precise analysis of the complete strut apposition and strut coverage, the optic coherence tomography (OCT) has been extensively used for stent analysis. The aim of this study was to assess the struts coverage and apposition of DES BioMatrixTM in a long-term follow up. Methods: Twenty patients undergoing a BioMatrixTM (n = 15) or BMS S-StentTM (n = 5) implantation were followed up for a period of at least five years and evaluated by means of OCT, quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS). All statistical analyses were performed using SPSSTM (v.16.0) and SAS (v.9.2) software. Statistical significance was considered at p values < 0.05. Categorical variables were expressed as counts and percentages, and continuous variables as mean SD and/or median and interquartile range. For per-patient level comparison, the difference between two stent types was evaluated by nonparametric Mann-Whitney U test while categorical variables were evaluated by the Fisher exact test. Results: QCA analysis showed no differences in the occurrence of intrastent late loss between the groups [0.40 (0.21; 0.77) mm vs 0.68 (0.66; 0.82) mm, p = 0.205 for BioMatrixTM and S-StentsTM, respectively]. The vessel, stent and lumen volumes assessed by IVUS after the procedure and 5 years later were similar between the two groups. Patients treated with BioMatrixTM had significantly less stent obstruction percentage when compared to those treated with S-StentTM [5.6 (4.4; 9.7)% vs 28.6 (24.7; 29.0)%, p = 0.001]. OCT analysis demonstrated 126 (8.7%) uncovered struts in the BioMatrixTM group compared to 23 (4.0%) in the S-StentsTM group (p = 0.297), being the majority of them well apposed (117/126 and 21/23, respectively, p = 0.292). Only 9 (0.6%) struts in the DES and 2 (0.4%) struts in the BMS groups were imultaneously uncovered and malapposed (p = 0.924). Among the BioMatrixTM patients, 55.6% (5/9) had more than 95% of covered struts and in only 1 (11.1%) patient all struts were covered. On the other hand, among the S-StentTM patients, 66.7% (2/3) had complete covered struts (p = 0.127). Conclusion: Long term assessment of DES BioMatrixTM by OCT showed tissue coverage and apposition in almost all struts, similary to those found in the BMS S-StentsTM.

Hepatocellular carcinoma is a primary liver cancer.Among treatment options for hepatocellular carcinoma, Yttrium-90 radioembolization is a promising transarterial therapy.This thesis investigates potential clinical applications of radioembolization in the treatment of the hepatocellular carcinoma (techniques of radiation segmentectomy and radiation lobectomy), and adress the problematic of the response Assessment after radioembolization. / Doctorat en Sciences médicales (Médecine) / info:eu-repo/semantics/nonPublished

Abstract Endovascular aneurysm repair (EVAR) is a minimally invasive alternative to open surgery to exclude an abdominal aortic aneurysm from the circulation to avert a rupture. The aim of this thesis was to evaluate the early and mid-term results of EVAR using the Zenith® stent-graft (Cook Inc, Bloomington, IN, USA) in asymptomatic and symptomatic abdominal aortic aneurysm (AAA) patients in three Finnish university hospitals. Furthermore, the aim was to study whether preoperative embolization of the inferior mesenteric artery (IMA) before EVAR decreases the incidence of a type II endoleak or has an effect on the aneurysm sac shrinkage. Finally, the results after secondary interventions for a type II endoleak were evaluated. Two hundred six patients underwent elective endovascular repair of an intact AAA. The use of the Zenith® stent-graft was associated with good early and mid-term results. The thirty-day mortality rate (2.9%) was in accordance with other EVAR studies. Only one late aneurysm-related death occurred in this series, whilst no patients died of a late aneurysm rupture. No stent-graft migrations or fractures were observed. Endoleak, defined as persistent blood flow outside the graft and within the aneurysm sac, remains a long-term problem with EVAR. The overall endoleak incidence was 34.6%. A type II endoleak (retrograde perfusion via aortic side branches) occurred in 52 patients (25.4%). EVAR was performed for 14 patients with a symptomatic, unruptured AAA. The median delay from admission to intervention was 4 days. EVAR of a symptomatic, unruptured AAA was associated with a favourable outcome even in patients with a very high operative risk. There were no perioperative deaths. Altogether forty patients treated at Kuopio University Hospital had a patent IMA on preoperative computed tomography (CT) and were treated successfully with coil embolization before EVAR. Thirty-nine patients who underwent EVAR at Oulu University Hospital without preoperative embolization of a patent IMA served as a control group. Preoperative coil embolization of the IMA significantly reduced the incidence of type II endoleaks after EVAR, but the present study failed to show any influence on late postoperative aneurysm sac shrinkage. Overall, 14 patients underwent a secondary intervention to repair the type II endoleak. Ten patients had transarterial embolization and four patients had translumbar embolization. The results were unsatisfactory; clinical success after the first secondary intervention was achieved in only two patients in the transarterial embolization group and three patients in the translumbar embolization group. These results seem to favour direct translumbar embolization rather than transarterial embolization. In conclusion, EVAR with the Zenith® stent-graft is effective in excluding AAAs from the circulation and is associated with good mid-term results.

Portal hypertension (PHT) is a condition with serious complications, such as variceal bleeding, refractory ascites and bowel ischemia. The cause of PHT may be pre-, intra- or post-hepatic. Initial treatment is pressure-reducing drugs and the treatment of acute symptoms. Ten patients presented with severe abdominal pain and acute portomesenteric venous thrombosis. Their response to systemic anticoagulation was insufficient. Treatment with primary continuous thrombolysis by a transhepatic or transjugular approach in four patients resulted in major complications, incomplete recanalization and a 75% survival rate. Treatment with repeated transjugular thrombectomy (TT) combined with the creation of a transjugular intrahepatic portosystemic shunt (TIPS) achieved near complete recanalization, prompt symptom relief and 100% survival in five patients treated with this method as the primary intervention. In one patient, treated with TT and TIPS secondary to surgical thrombectomy and bowel resection, the outcome was fatal. Nineteen patients with portal vein thrombosis presented with acute or threatening variceal bleeding or refractory ascites. TIPS was feasible in 16 of the 18 patients in whom it was attempted and symptom relief was achieved in the majority of them. In 14 patients with Budd-Chiari syndrome, 13 patients were treated with TIPS, four of them after previous liver vein angioplasty. The 5-year transplantation-free survival rate was 100% in patients treated with primary TIPS. In 131 patients with variceal bleeding treated with TIPS, the survival at 12 months in patients with and without cirrhosis was 70% and 100% respectively and in accordance with previous studies. A high Child-Pugh score prior to TIPS and severe HE within 12 months after TIPS was related to an increased mortality. The occurrence of HE after TIPS did not correlate with the PSG after TIPS. Re-bleeding within 12 months after TIPS occurred in 10 patients and was associated with TIPS dysfunction. In conclusion, endovascular intervention, mainly TIPS, seems to be safe and effective for treating patients with complications of PHT, regardless of the underlying cause of disease and site of venous blood flow obstruction. HE may occur more frequently after TIPS than medical and endoscopic treatment, but is often mild and easily treated. In selected patients with PHT, TIPS may improve survival.

L’optimisation du guidage en radiologie interventionnelle implique de simplifier les gestes, d’améliorer la qualité d’images et leur précision tout en réduisant l’exposition aux rayons X du personnel soignants et des patients et l’usage du produit de contraste iodé, néphrotoxique. Elle implique un travail sur chacune des quatre étapes fondamentales de chaque intervention que sont : « voir », « atteindre », « intervenir » et « contrôler » le succès de l’intervention et l’absence de complication.L’étape « voir » la cible a fait l’objet de 3 études : la première, animale, portait sur l’amélioration de la qualité d’images de cone-beam computed tomography (CBCT) et la seconde, clinique, sur la précision de la segmentation des tumeurs hépatiques mise en évidence sur les images de CBCT lors de chimioembolisations (CHE). Et enfin, la troisième, clinique, sur le repérage des artères épigastriques inférieures profondes en réalité augmentée avant lambeau.L’étape « atteindre » la cible a fait l’objet de 5 études. Deux études ont validé la précision du ciblage des tumeurs hépatiques lors des CHE utilisant des logiciels de détection automatique des artères nourricières et de perfusion virtuelle du territoire tumoral à traiter sur les images de CBCT lors de CHE. Trois autres études portaient sur les cartographies 3D par la technique de fusion d’images 3D projetées sur la fluoroscopie 2D. Les deux premières premières ont montré que l’usage de la fusion d’images lors des traitements endovasculaires des anévrismes complexes de l’aorte abdominale utilisant les images d’angioscanner ou d’angioIRM préopératoires permettant de réduire voire de s’affranchir de l’usage de produit de contraste iodé dans la prise en charge de ces pathologies. Le développement de la fusion d’images notamment lors du placement de shunt porto-systémique trans-hépatique par voie trans-jugulaire a permis de faciliter ces interventions tout en limitant l’usage des rayons X dans une troisième étude.La troisième étape « interventir » a fait l’objet de trois études. Une étude, fantôme, a montré la possibilité d’obternir une imagerie sélective et quantitative des structures iodées par l’imagerie spectrale des microsphères chargées d’huile iodée. Une seconde étude préclinique animale a attesté la radioopacité de ces mêmes microsphères chargées lorsqu’elles s’accumulent dans les capillaires ou néovaisseaux et sont le reflet de la nécessité de combiner une recherche commune sur le couple imagerie/matériel. Et enfin l’étude sur la rentabilité des biospies des tumeurs guidées par l’image qui a permis de mettre fin à des dogmes.La quatrième étape « contrôler » le succès des traitements comprend deux études. La première, est une revue de la littérature et a permis de proposer une standardisation de l’usage du CBCT lors des CHE et la seconde a évalué différents facteurs prédicteurs de réponse tumorale en IRM après CHE avec un intérêt particulier porté sur l’usage de nouveaux critères d’analyse 3D (vRECIST et qEASL).Le guidage en radiologie et notamment par le CBCT est encore confronté à la limitation majeure qu’est d’utiliser des rayons X et des produits de contraste iodé mais également à un champ de vue limité et à une qualité d’images sensibles aux artéfacts. D’ou le développement d’autre moyen de guidage comme l’IRM, éléctromagnétisme, fibroptique ou encore la réalité augmentée. Ces derniers éléments font partis de projets de recherche en cours ou à venir. / Optimizing image guidance in interventional radiology involves simplifying procedures, improving image quality and accuracy while reducing X-rays exposure, and the use of iodinated contrast media, which is nephrotoxic. It involves to improve each of the four fundamental steps of each intervention: "see", "reach", "intervene" and "control" the success of the intervention and the absence of complication.To "see" the target was the subject of 3 studies: the first study, was an animal study focused on improving the quality of images of cone-beam computed tomography (CBCT). The second study was a clinical study about the precision of the tumor segmentation of on CBCT images during chemoembolization (TACE). And finally, the third study was a clinical study and described the identification of the lower deep epigastric arteries in augmented reality before flap.To "reach" the target was the subject of 5 studies. Two studies investigated the accuracy of hepatic tumor targeting in TACE using automatic feeding detection and virtual tumor perfusion software on CBCT images. Three other studies were focused on 3D roadmap using the image fusion technique overlaid onto 2D fluoroscopy. The two first studies were about endovascular treatments of complex abdominal aortic aneurysms using images fusion based on angiography of computed tomography or IRM to reduce or even eliminate the use of iodinated contrast agent in the management of such disease. The development of image fusion, particularly during trans-hepatic porto-systemic shunt placement, was shown to facilitate these interventions while limiting the use of X-rays published in to a thrid study.To "intervene" step included three studies. A phantom study showed that spectral imaging displayed selective and quantitative images of iodine content of iodine-loaded microspheres. A preclinical study demonstrated their visibility on x-ray based imaging when they accumulated in capillaries or neovessels and reflected the need to combine a common search for the couple imaging / biomaterials. And finally the study on the rentability of the image guided biospies of tumors which allowed to end dogmas.To "control" the success of treatments included two studies. The first study is a review of the literature and allowed a standardization of the use of the CBCT during the TACE and the second evaluated the factors predictors of tumor response on MRI images after TACE by the use of new 3D criteria. Image guidance with the use of CBCT, is still confronted with the major limitation of the use of X-rays and iodinated contrast media, but also to a limited field of view and a sentitive images quality to artefacts. Hence the development of other image guidance types such as MRI, electromagnetism, fibroptic or augmented reality are on its way. These last elements are part of a research projects in progress or to come.