Articles

Articles are a collaborative effort to provide a single canonical page on all topics relevant to the practice of radiology. As such, articles are written and edited by countless contributing members over a period of time. A global group of dedicated editors oversee accuracy, consulting with expert advisers, and constantly reviewing additions.

88 results found
Article

Abdominal paracentesis

Abdominal paracentesis, more commonly referred to as an ascitic tap, is a procedure that can be performed to collect peritoneal fluid for analysis or as a therapeutic intervention. Indications diagnostic: especially for newly diagnosed ascites determine aetiology of ascites assess for bacter...
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Amniocentesis

Amniocentesis (also known as amniotic fluid testing or AFT), is a diagnostic or therapeutic medical procedure primarily used in prenatal diagnosis of chromosomal abnormalities and fetal infections. A small amount of amniotic fluid (15-20 ml), which contains fetal tissue, is extracted from the a...
Article

Arteriovenous access

Arteriovenous access is required for haemodialysis in renal failure patients. The upper limb is generally preferred as a site, however, lower limb access can also be obtained. Ultrasound is the preferred modality for evaluation of the vessels prior to creating an access. Types arteriovenous fi...
Article

Brachytherapy

Brachytherapy, also known as sealed source radiotherapy or endocurietherapy, is a form of radiotherapy where a radioactive source is placed, under the guidance of imaging, within or next to the area requiring treatment. Brachytherapy is commonly used to treat localised prostate cancer, breast c...
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Breast core biopsy

Percutaneous breast biopsy is one of the current choices for focal histopathological assessment of breast lesions. In contrast to fine needle aspiration, during a core needle biopsy, a hollow needle is used to withdraw small cores of tissue from the area of interest in the breast.  This procedu...
Article

Breast ductography

Breast ductography (a.k.a. galactography) is an imaging technique which is used to evaluate lesions causing nipple discharge. It helps in precisely locating the mass within breast tissue and gives useful information for surgical approach and planning. Technique A blunt-tipped sialogram needle ...
Article

Buried bumper syndrome

Buried bumper syndrome (BBS) is a rare but important complication in patients with percutaneous endoscopic gastrostomy (PEG) tube, occurring by migration of the internal bumper along its track. The tube may get lodged anywhere between the gastric wall and the skin and lead to life-threatening co...
Article

Carotid arterial stenting

Carotid arterial stenting (CAS) is a minimally invasive endovascular interventional procedure that can potentially offer the same advantage as surgery (carotid endarterectomy). Indications Indications for carotid stenting are evolving with endarterectomy trials that evaluate the carotid stenos...
Article

Caudal epidural injection

Caudal epidural injections, or sacral hiatus epidural injections, are one of several possible spinal epidural injections.  Indications Typically, epidural injections are performed in patients who are currently not surgical candidates. The caudal injection can be performed when patients are on ...
Article

Cell block cytology

Cell block cytology is a technique used in cytopathology (in addition to smears) for evaluation of tissue from fine needle aspirations or fluid aspirations. Multiple different protocols exist for processing a cell block, but the fundamental principles are the same: fragmentary bits of tissue (...
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Central venous catheter

Central venous catheters (CVC) or lines (CVL) refer to a wide range of central venous access devices but can broadly be divided into four categories. They may be inserted by physicians, surgeons or radiologists. Classification peripherally inserted central catheters (PICC) non-tunnelled CVCs ...
Article

Cerebral angiography

Cerebral angiography is an interventional procedure for the diagnosis and/or treatment of intracranial pathology. Indications Cerebral digital subtraction angiography (DSA) is indicated in a variety of settings including: diagnosis and treatment of: aneurysms acute ischaemic stroke vascula...
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Cervical interlaminar epidural injection

Cervical interlaminar epidural injections are one of some possible spinal epidural injections. For an alternative approach for the same region, please refer to the article on cervical transforaminal epidural injections.  Indications Typically epidural injections are performed in patients with ...
Article

Chorionic villus sampling

Chorionic villus sampling (CVS) is an antenatal procedure for prenatal diagnosis of chromosomal or genetic disorders in the fetus. It entails getting a sample of the chorionic villus (placental tissue) and testing it. A transabdominal or transcervical approach is selected depending on the posit...
Article

CT guided adrenal biopsy

CT guided adrenal biopsy is usually performed for the diagnosis of indeterminate adrenal nodules or tumours. This procedure has declined in recent years due to improvements in, and validation of, non-invasive CT and MR techniques that can now diagnose benign adrenal lesions with a high degree of...
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CT guided percutaneous drainage

CT guided percutaneous drainage is one form of image-guided drainage, allowing minimally invasive treatment of collections, potentially anywhere in the body. Although less commonly used than ultrasound guidance, it is particularly valuable in gaining access to deeper or more posterior parts of t...
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CT guided thoracic biopsy

CT guided thoracic biopsy is usually performed for the diagnosis of suspicious lung, pleural or mediastinal lesions. It can be performed as an outpatient where patient monitoring and complications support are available. Indications pulmonary lesion inaccessible to bronchoscopy, or in which pri...
Article

Endoleak

Endoleaks are characterised by persistent blood flow within the aneurysm sac following endovascular aneurysm repair (EVAR). Normally the aortic stent-graft used for EVAR excludes the aneurysm from the circulation by providing a conduit for blood to bypass the sac. Epidemiology An endoleak is a...
Article

Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and interventional procedure technique using both endoscopy and fluoroscopy for examination and intervention of the biliary tree and pancreatic ducts. It is typically performed by doctors with endoscopic qualifications (e.g. g...
Article

Endotension

Endotension, also referred to as a type V endoleak, is not a true leak but is defined as continued expansion of the aneurysm sac greater than 5 mm, without radiographic evidence of a leak site. Pathology It is a poorly understood phenomenon but thought to be formation of a transudate due to ul...
Article

Endovascular aneurysm repair

Endovascular aneurysm repair (EVAR) was first pioneered in the early 1990s. Since then technology of the devices has rapidly progressed and EVAR is now widely used as treatment of thoracic and abdominal aortic aneurysms (AAA). The advantages of endovascular repair over open repair is that they ...
Article

Epidural blood patch

Epidural blood patch is a treatment option for patients with craniospinal hypotension or post lumbar puncture headaches. The procedure can be done blind or under fluoroscopic or CT guidance, and is performed predominantly by radiologists and anaesthetists.  Indications craniospinal hypotension...
Article

Facet joint injection

Facet (zygapophyseal) joint injections are one of the most frequently performed spinal interventional procedures, as both treatment for and diagnosis of radicular pain syndrome and facet syndrome. It can be performed under fluoroscopic, or CT image guidance and cervical, thoracic or most commonl...
Article

Femoral artery pseudoaneurysm

Femoral artery pseudoaneurysms are usually iatrogenic as the femoral artery is the vessel of choice for most endovascular arterial interventions. Pathology Aetiology iatrogenic anticoagulation therapy inadequate compression following endovascular intervention improper arterial puncture tec...
Article

Fine needle aspiration (FNA)

Fine needle aspiration (FNA) is a type of minimally-invasive tissue sampling. It often uses ultrasound as a targeting instrument, although CT, and even MRI or fluoroscopy could potentially be used, depending on the situation. Imaging guidance is particularly useful when sampling deep or diffuse ...
Article

Flow-diverter stent

Flow-diverter stents are relatively new and important devices in the management of intracranial aneurysms, especially ones that are large, broad-necked or fusiform.  Complications In a multi-centre study in Italy, Briganti et al reported an overall morbidity rate of 3.7% and a mortality rate o...
Article

Fluoroscopic nasojejunal tube insertion

Fluoroscopic nasojejunal (NJT) or nasogastric tube (NGT) insertion is a valuable procedure offered by radiologists in patient care. The majority of nasogastric tubes are inserted on the ward level and nasojejunal tubes may be placed in theatre at the time of surgery. In difficult cases, inserti...
Article

Fluoroscopy-guided lumbar puncture

Fluoroscopy-guided lumbar punctures (LPs) are a minimally invasive, image-guided diagnostic and therapeutic procedure that involves the removal of a small volume of cerebrospinal fluid (CSF), or an injection of medication or other substance (e.g. radiotracer, chemotherapy agents) into the lumbar...
Article

Gene expression classifier

A gene expression classifier (GEC) test is a developing technology in the pathologic analysis of thyroid nodules, using tissue from a fine needle aspiration. The test is designed to help classify "indeterminate" thyroid nodules, and therefore avoid surgery for indeterminate nodules th...
Article

Glenohumeral hydrodilatation

Glenohumeral hydrodilatation (tension arthography) is an established treatment for adhesive capsulitis of the shoulder (frozen shoulder) and can be performed under multiple modalities.  Indications adhesive capsulitis of the shoulder Contraindications anticoagulation/coagulopathy systemic s...
Article

Hepatic chemosaturation

Hepatic chemosaturation is a percutaneous technique used to locally treat unresectable hepatic metastases in patients without systemic disease. Technique The key to this technique is isolating the blood supply to the liver. This is achieved by: closure of the gastro-duodenal artery by coiling...
Article

HOT Pepper (mnemonic)

A mnemonic to recall the persistent communications between the anterior (carotid) and posterior (vertebrobasilar) systems is: HOT Pepper Knowledge of these anatomical variants is important to avoid confusion with pathology and to prevent inadvertent injury during surgery. Mnemonic H: hypoglo...
Article

Image guided percutaneous renal biopsy

Image guided percutaneous renal biopsy, utilising either ultrasound or CT allows for an accurate, reliable method of acquiring renal tissue for histopathological assessment. Biopsy may be of a native or transplant kidney. It is divided into two types: non-focal or non-targeted focal or target...
Article

Infusothorax

Infusothorax is a complication of central venous catheter malposition where the catheter tip is located in the pleural space and the infusion of the fluid collects inadvertantly in the pleural space in the form of a pleural effusion. Longer term complications depend on the fluid being infused.
Article

Interventional procedure article structure

Interventional articles necessarily require a different structure to other articles. It is important for them to have a consistent structure to maintain uniformity across the site. The suggested structure and headings (and heading size) are as follows: ==========================================...
Article

Intra-aortic balloon pump

Intra-aortic balloon pumps (IABP) are used in the intensive care setting to provide haemodynamic assistance to patients in cardiogenic shock. Function and physiology The device is comprised of a catheter introduced via the femoral artery, which extends retrogradely to the proximal descending t...
Article

Irreversible electroporation

Irreversible electroporation (IRE), also known as non-thermal irreversible electroporation (NTIRE), is a non-invasive soft-tissue ablation technique used for tumour ablation in regions that require very high precision and preservation of surrounding structures. Mechanism In IRE electrodes are ...
Article

Jugular venous catheters

The internal jugular vein is a preferred site for venous access for large lumen, long-term central venous catheters for chemotherapy, haemofiltration and plasma exchange.  Typically, the right internal jugular is used as its vertical course straight down into the superior vena cava via the righ...
Article

Liver and biliary interventional procedures

There is a wide range of liver and biliary interventional procedures, both diagnostic and therapeutic, most commonly using CT-guidance or ultrasound-guidance.   Percutaneous transhepatic biliary interventions percutaneous transhepatic cholangiography (PTC) percutaneous transhepatic biliary dr...
Article

Lumbar interlaminar epidural injection

Lumbar interlaminar epidural injections are one of some possible spinal epidural injections. For an alternative approach for the same region, please refer to the article on lumbar transforaminal epidural injections.  Indications Typically, epidural injections are performed in patients with rad...
Article

Magnetic resonance cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique to visualize intra and extrahepatic biliary tree and pancreatic ductal system. It can provide the diagnostic range equivalent to the ERCP and so it can replace the ERCP in high risk patient to avoid significa...
Article

Nephrostomy

Nephrostomy is a common urologic or interventional radiology procedure in which a tube/catheter is introduced into the renal collecting system (usually the renal pelvis). Nephrostomies can either be "open" nephrostomy: after a urological surgical procedure, such as a UPJ stone remova...
Article

Oesophageal stent

Oesophageal stents are a treatment option in patients with oesophageal strictures. It is most commonly used for symptomatic relief in those with dysphagia secondary to malignancy. The stent is typically covered in nature and inserted endoscopically or fluoroscopically. The distal oesophagus is t...
Article

Percutaneous cholecystostomy

Percutaneous cholecystostomy is an image-guided placement of drainage catheter into gallbladder lumen. This minimally invasive procedure can aid stabilisation of a patient to enable a more measured surgical approach with time for therapeutic planning. Indications poor surgical candidate/high r...
Article

Percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a procedure where a is a flexible feeding tube (commonly known as a PEG tube) is inserted through the abdominal wall and into the stomach. This may be placed under endoscopic or radiological guidance, in the latter the procedure may be known as a perc...
Article

Percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is a surgical procedure for the extraction of large renal calculi. It is usually performed in the operating theatre either by a urologist or combined urologist-radiologist team. Indication PCNL is used to destroy and remove renal calculi, typically over 2 cm...
Article

Percutaneous nephrostomy

Percutaneous nephrostomy is a technique in which percutaneous access to the kidney is achieved under radiological guidance. The access is then often maintained with the use of an indwelling catheter. Indications urinary tract obstruction urinary diversion (e.g. ureteric injury; urine leak) a...
Article

Percutaneous nephrostomy salvage and tube exchange

Percutaenous nephrostomy salvage and tube exchange are two procedures undertaken in those with long term nephrostomies. These patients are often either unsuitable or do not wish to have ureteric stenting to relieve their urinary tract obstruction. Nephrostomy salvage Nephrostomy salvage is und...
Article

Percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage is an interventional radiology procedure undertaken for those with biliary obstruction. It is almost exclusively performed in those with malignant obstruction, such as cholangiocarcinoma, ampullary and pancreatic malignancies when retrograde access via...
Article

Peripherally inserted central catheters

Peripherally inserted central catheters (PICC), often called PICC lines, are a type of central venous catheter predominantly used amongst oncology patients and those with chronic diseases (e.g. cystic fibrosis). They offer the ability to have long-term central venous access without the need to ...
Article

Pinch off syndrome

Pinch-off syndrome is a spontaneous catheter fracture, which is seen as a complication of subclavian venous catheterisation. Epidemiology It is a known complication of central venous catheterisation with a much-reduced incidence in current practice and is generally considered to be rare. Radi...
Article

Portal vein embolisation

Portal vein embolisation (PVE) is a technique used to selectively occlude the blood supply to one of the liver lobes, allowing the the other lobe to undergo hyperplasia. This increases the size of the post hepatectomy future liver remnant (FLR), and improves surgical outcomes. PVE is a procedur...
Article

Programmable cerebrospinal fluid shunt

The programmable cerebrospinal shunt valve is a type of ventriculoperitoneal shunt that can be set to different pressure setting. It is of particular value in normal pressure hydrocephalus and in paediatrics patients. The 2010 AJNR article by Lollis et al. 1 provides radiographic features of th...
Article

Prostatic artery embolisation

Prostatic artery embolisation (PAE) is a minimally invasive procedure option utilised to treat the benign prostatic hyperplasia (BPH).  Indications PAE has been used for controlling prostatic haemorrhage (such as those associated prostate cancer) since 1970. However, its use in the treatment o...
Article

Radio-embolisation

Radio-embolisation is the delivery of radio-active microspheres to cancers using an endovascular approach. It is often performed as an outpatient procedure.  Indications primary liver cancer or liver metastases bilirubin of <2.0 tumour size less that than 70% of liver size Contraindicati...
Article

Radiofrequency ablation

Radiofrequency ablation is a medical procedure that uses a high frequency alternating current produced by a radiofrequency generator oscillating in a closed loop circuit. This high frequency current causes heating to over 60 °C which leads to protein denaturation and tissue damage. Applications...
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Renal artery pseudoaneurysm

Renal artery pseudoaneurysms are uncommon vascular finding, with the majority occuring after a renal intervention. Pathology A renal artery pseudoaneurysm differs from a renal artery true aneurysm (as might occur in fibromuscular dysplasia) in that it does not involve all three layers of the a...
Article

Renal sympathetic denervation

Renal sympathetic denervation (RSDN), also known as renal denervation, is an interventional procedure that uses radiofrequency ablation to destroy the nerve endings in the wall of the renal arteries. Endovascular (trans-catheter) techniques are an alternative to surgical sympathectomy.  Indicat...
Article

Rotational occlusion of the vertebral artery

Rotational occlusion of the vertebral artery, also known as Bowhunter syndrome, is a rare form of posterior cerebral circulation ischemia secondary to dynamic compromise of the dominant vertebral artery. It has many aetiologies, but is most often due to large osteophytes or atlanto-axial hyperm...
Article

Sacroiliac joint injection

Sacroiliac joint injections can be performed using a posterior approach into the the sacroiliac joint under fluoroscopic or CT guidance.
Article

Sandbox (test page)

Feel free to edit this page however you want, if you want to just play and see how editing works.  Subheadings bullets  more bullets more bullets Capitalisation words after bullets should not be capitalized until they represent a name, e.g. Churg-Strauss syndrome will have "C" an...
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Segmental arterial mediolysis

Segmental arterial mediolysis (SAM) is an increasingly recognised vascular disease of the middle-aged and elderly and a leading cause of spontanoeus intra-abdominal haemorrhage. It is characterised by fusiform aneurysms, stenoses, dissections and occlusions within splanchnic arterial branches. I...
Article

Sialography

Sialography is the imaging of the salivary glands, most commonly the parotid gland.  The salivary ducts are conventionally examined fluoroscopically with high sensitivity, though cross-sectional imaging with CT or MR sialography have also been described. Indications suspected sialolithiasis or...
Article

Sniff test

The fluoroscopic sniff test, also known as diaphragm fluoroscopy, is a quick and easy real time fluoroscopic assessment of diaphragmatic motor function (excursion). It is used most often to confirm absence of muscular contraction of the diaphragm during expiration in patients with phrenic nerve ...
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Spinal epidural injection

Epidural spinal injections are one of the more frequently performed spinal interventional procedures.Three approaches to the epidural space exist: transforaminal epidural injection interlaminar epidural injection cervical interlaminar epidural injection lumbar interlaminar epidural injection...
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Spinal interventional procedures

Back pain is a common condition that is often difficult to treat. Lumbar degenerative facet joints, lumbar disc disease and sacroiliac joint pain account for nearly 70% of cases of lower back pain. Unfortunately, as the incidence of degenerative changes in the spine is so high (e.g. disc abnorm...
Article

Splenic embolisation

Splenic (artery) embolisation is an endovascular technique for treatment of splenic and splenic artery pathology as an alternative to splenic artery ligation or splenectomy. It often results in successfully treating the underlying pathology, while maintaining at least partial splenic function.  ...
Article

Stereotactic breast biopsy

Breast biopsy is performed whenever it becomes necessary to characterise a breast lesion. This consists of the withdrawal and collection of cells (cytologic exam) or tissue fragments (histologic exam) and in the anatomical-pathological analysis of the sample tissue.  There are many different wa...
Article

Subacromial bursal injection

Subacromial corticosteroid injection is reserved for patients with no response to initial treatment with impingement syndrome, subacromial bursitis and/or rotator cuff disorders. Nonsteroidal anti-inflammatory drugs (NSAIDs) and activity modification are the initial treatments to reduce the pain...
Article

Sunburst sign - renal angiomyolipoma

The sunburst sign refers to the appearance of arterial blush seen at selective arterial DSA angiography of a renal angiomyolipoma. Angiomyolipoma is a hypervascular renal mass that shows dense early arterial vascular network of tortuous irregular vessels with micro- or macro-aneurysms.
Article

T tube cholangiogram

T-tube cholangiograms are a fluroscopic study performed in the setting of hepatobiliary disease. Typically a T-shaped tube is left in the common bile duct at the time of surgery (e.g. cholecystectomy) and allows for exploration of the common bile dict (choledochotomy) and retrieval of common bi...
Article

Thoracentesis

Thoracentesis, commonly known as a pleural or chest tap, is a procedure where excess pleural fluid is drained from the pleural space for diagnostic and/or therapeutic reasons. Ultrasound-guided thoracentesis performed by radiologists has been shown to have fewer complications than blind thoracen...
Article

TIPS evaluation

TIPS evaluation is useful to ensure that the shunt is working properly and that no stenosis has occurred within the stent. Ultrasound is often used as a first line modality. Radiographic features Ultrasound The normal TIPS should show colour Doppler flow throughout its length. The in-stent ve...
Article

Transcatheter arterial chemoembolisation

Transarterial chemoembolisation therapy (TACE) is a localised method of administrating chemotherapy directly to the liver tumor via a catheter study. Transarterial embolisation (TAE) (i.e. without a chemotherapy agent added) is also used and there is evidence that this may be just as effective ...
Article

Transforaminal nerve root injection

Transforaminal nerve root injfection is performed for radicular pain treatment and diagnosis. See spinal interventional procedures for complications and equipment. cervical spine thoracic spine lumbar spine The desired needle tip position is just lateral to the pedicle immediately below the...
Article

Transjugular intrahepatic portosystemic shunt (TIPS)

A transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for portal hypertension in which a direct communication is formed between a hepatic vein and a branch of the portal vein, thus allowing some proportion of portal flow to bypass the liver. The target portosystemic gradient afte...
Article

Transjugular renal biopsy

Transjugular renal biopsy can be performed to obtain an adequate tissue sample for histopathologic diagnosis on renal dysfunctions. It is usually performed in high-risk patients in whom percutaneous renal biopsy is not feasible or is contraindicated. This is also useful in morbidly obese patient...
Article

Ultrasound guided biopsy

Ultrasound guided biopsy is one form of image guided biopsy, typically performed by a radiologist.  It is the most common form of image guided biopsy, offering convenience and real time dynamic observation with echogenic markers on cannulae allowing for precise placement. It can potentially be ...
Article

Ultrasound guided breast biopsy

Ultrasound guided percutaneous breast biopsy is a widely used technique for an accurate histopathological assessment of suspected breast pathology. It is a fast, safe and economical procedure. Indications Ultrasound guidance is limited to lesions visible on ultrasound study, such as:  BIRADS ...
Article

Ultrasound guided percutaneous drainage

Ultrasound guided percutaneous drainage is one form of image guided procedure, allowing minimally invasive treatment of collections that are accessible by ultrasound study. It has several advantages and disadvantages over CT, which include: Advantages is a dynamic study, allowing greater prec...
Article

Ultrasound guided peripheral intravenous cannulation

Ultrasound (US) guided peripheral intravenous cannulation (IVC) is the placement of a cannula into a peripherally located vein under the direct vision of ultrasound. This process allows the cannulation of veins that are unable to be visualised or palpated without ultrasound. In trained individua...
Article

Ureteric stent

Ureteric stents, also known as double J stents or retrograde ureteric stents, is a urological catheter that has two "J-shaped" (curled) ends, where one is anchored in the renal pelvis and the other inside the bladder. Stents are used for the free passage of urine from the kidney to th...
Article

Urethral clamps

Various radiological and surgical instruments, including urethral clamps, have been developed to try to improve retrograde/ascending urethrogram (RUG/ASU) and voiding cystourethrogram (VCUG) technique in males. These are very rarely (if ever) used anymore. Brodny clamp This device has a metall...
Article

Urethrography

Urethrography refers to the radiographic study of the urethra using iodinated contrast media and is generally carried out in males.  Terminology When the urethra is studied with instillation of contrast into the distal/anterior urethra it has been referred to as retrograde urethrography (RUG)...
Article

Varicocoele embolisation

Varicocoele embolisation is a method treating varicocoeles by embolising the testicular vein. Indications symptomatic varicocoele infertility/subfertility failed surgical ligation Contraindications Relative contraindications include: intravenous contrast allergy renal impairment coagulo...
Article

Vena cava filter

Vena cava filter is an endovascular device which is typically placed in the infrarenal inferior vena cava (IVC) to prevent pulmonary embolism in selected patients. This procedure is most often performed by interventional radiologists under fluoroscopic guidance. Indications contraindication to...
Article

Vertebroplasty

Vertebroplasty is an imaging-guided procedure which entails percutaneous injection of surgical polymethylmethacrylate or cement into a diseased vertebra. Vertebroplasty provides pain relief and strengthening of the bone of vertebrae weakened by disease. Indications It can be used in the treatm...
Article

Watchman device

Watchman device is a permanent left atrial appendage closure device, which is percutaneously implanted to prevent embolisation of thrombus from the appendage into systemic circulation in cases atrial fibrillation. It is used when there is contraindication to anticoagulation or high risk of lifel...

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