NON-VASCULAR IMAGE-GUIDED INTERVENTIONAL PROCEDURES: GENERAL GUIDELINES AND MATERIALS

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1 NON-VASCULAR IMAGE-GUIDED INTERVENTIONAL PROCEDURES: GENERAL GUIDELINES AND MATERIALS Horacio D Agostino, MD 1

2 PERCUTANEOUS BIOPSY DEFINITION: To obtain a tissue specimen for diagnosis of normal or abnormal conditions (benign or malignant). Biopsy samples may be sent to microbiology for Gram stain, culture and sensitivity if contamination or infection is suspected. ANESTHESIA: Conscious sedation (intravenous, midazolam/fentanyl) and local IMAGE-GUIDANCE: Fluoroscopy, Sonography, Computerized Tomography and Magnetic Resonance. PATIENT POSITION: Tailored to each patient, depends on the location of the lesion. OPERATOR POSITION: On the same side of lesion 1. Biopsy Tray: Sterile field with large central opening, 2 Luer lock disposable syringes (10 ml), 1 connecting tube, 2 needles (18 g and 25 g, 1.5 ), 1 Kelly clamp, 4x4 gauze (small pack). 2. Needles (focal lesions require fine needles, core biopsies are performed with automatic needles) Type Length (cm) Size (gauge) Spinal Chiba Automatic Coaxial sets 3. Lung and mediastinal biopsy: Have 10 Fr catheter ready to insert in the chest in case of symptomatic pneumothorax, pneumothorax >30% of the hemithorax volume, or to continue the biopsy. Chest tube to be connected to Heimlich valve and/or Pleurevac. Watch for most common complications: bleeding, perforation and pain. There are a wide variety of needles available for biopsy performance. The above-mentioned are effective, commonplace and inexpensive. Bone and pleural biopsy require special needles. There are several companies that manufacture automatic needles for core biopsy. Almost all of them use the same cutting mechanism. Those simple to use are preferred. 2

3 DIAGNOSTIC/THERAPEUTIC ASPIRATION DEFINITION: Diagnostic aspiration is a procedure aiming at obtaining a sample of a fluid collection for diagnostic purposes (cytology, microbiology, chemistry, special tests). Therapeutic aspiration is a single stage procedure which goal is to evacuate completely symptomatic fluid collections to alleviate pain and discomfort. Diagnostic/therapeutic aspiration includes thoracentesis, paracentesis, and aspiration of fluid collections in the chest, abdomen, pelvis, and soft tissues. IMAGE-GUIDANCE: Sonography, Computerized Tomography. PATIENT POSITION: Tailored to each patient, depends on the location of the lesion. For diagnostic or therapeutic thoracentesis the patient may be sitting up. OPERATOR POSITION: On same side of lesion. a. Diagnostic aspiration Spinal needles gauge, 9 cm in length Chiba needles gauge, 9-25 cm in length Angiocath 16 gauge, 9-15 cm in length Yueh needle 19 gauge, 7-10 cm length b. Therapeutic aspiration Angiocath 16 gauge, 9-15 cm in length Yueh needle 19 gauge, 7-10 cm length WIRES: Floppy-J, heavy duty , 120 cm length DRAINAGE CATHETERS: Single lumen catheters 8-10 French, cm length, use of 60 cc syringe and evacuation set VACUUM BOTTLES ( ml). To be used for therapeutic aspiration of large ascites or fluid collections. Avoid its use in the chest (risk of re-expansion pulmonary edema). For thoracentesis have 10F catheter ready for pneumothorax drainage and a Pleurevac to connect catheter to. SPECIMENS ARE SENT FOR: Microbiology/Cell count/chemistry (ph for pleural effusion: 7.2 or less= empyema). MICROBIOLOGY SPECIMENS ARE DELIVERED STAT TO THE LABORATORY (Anaerobic bacteria may disappear within 5 min in contact with air) Watch for most common complications: bleeding, perforation and pain. 3

4 IMAGE-GUIDED FLUID COLLECTION DRAINAGE DEFINITION: Insertion of a catheter under image-guidance through the skin (percutaneous drainage), through the vagina (transvaginal drainage) or through the rectum (transrectal drainage) for evacuation of fluid (in a collection or anatomical cavity) IMAGE-GUIDANCE: Sonography (alone or combined with fluoroscopy or computerized tomography), computerized tomography, magnetic resonance. PATIENT POSITION: Tailored to each patient, depends on the location of the lesion. For thoracic drainage the patient may be sitting up on the procedure table or bed. A table is placed in front of the patient where she/he can lay during the procedure. OPERATOR POSITION: Same side of the lesion. 1. Angio pack 2. Localizing needles: Type Size Length Angiocath 16 gauge 7-15 cm Chiba gauge 9-20 cm Spinal gauge 9 cm 3. Catheters: Single lumen 8-28 Fr. Catheters may have a locking pigtail for internal fixation to prevent dislodgement. (For transvaginal and transrectal drainage this feature is a must!) 4. Wires: Heavy duty (or Amplatz 0.035, for transvaginal or transrectal, occasionally for other collections with little purchase) 5. External catheter fixation: Catheter sutured to the skin. Elastikon tape for additional external fixation (mesentery). 6. Drainage bag 7. Pleurevac for chest tube SPECIMEN IS SENT FOR: Microbiology/Cell count/chemistry of specimen (ph for pleural effusion: ph of 7.2 or less diagnostic of empyema). MICROBIOLOGY SPECIMENS ARE DELIVERED STAT TO THE LAB (Anaerobic bacteria may disappear within 5 min in contact with air) Watch for most common complications: bleeding, perforation and pain. 4

5 GASTROSTOMY/GASTROJEJUNOSTOMY DEFINITION: To insert a catheter into the stomach or the small bowel through the abdominal wall for nutritional support or gastrointestinal decompression. PATIENT PREPARATION: Nasogastric tube (NGT) or feeding tube in stomach. Give 100 ml of barium sulfate the night before the procedure. IMAGE-GUIDANCE: Sonography (to identify the liver margin), fluoroscopy, occasionally computerized tomography. PATIENT POSITION: Supine OPERATOR POSITION: Left side of patient (Right side optional for gastrostomy only) 1. NG in stomach 2. Glucagon 1 mg IV (available, rarely used) 3. General tray with 3 extra Kelly clamps 4. Percutaneous sutures (Meditech Brown-Mueller T-fasteners) 5. Wires: Gastrostomy: Heavy duty or Amplatz, 3 cm tip Gastrojejunostomy: Terumo, exchange Amplatz 6. Dilators 8,10,12,14 French 7. Catheters: Gastrostomy: Locking pigtail French Locking Malecot French (not in stock if used GI will have) Gastrojejunostomy: Directional catheters to go trough the pylorus an duodenum (hockey stick, cobra, etc.) Jejunostomy catheter 9-12 French Marx new cope 8.5 FR catheter and/or 04 FR Tiger catheter (Cook) 8, External fixation: Catheter sutured to the skin. Elastikon tape for additional external fixation (mesentery). Watch for most common complication: bleeding, peritonitis (from gastrostomy or colonic perforation). Prevent gastric dilatation and diarrhea by proper tube feeding. 5

6 Feedings 1. Percutaneous gastrostomy: NPO for 24 hours (parenteral hydration), start feeding at 24 hrs with 50 ml normal saline. If residual at 2 hours <50 ml, increase normal saline bolus to 100 ml. If residual at 2 hours < 50 ml, start feeding solution. THE GASTROSTOMY CATHETER IS FLUSHED WITH 20 ML NORMAL SALINE AFTER EACH FEEDING. 2. Percutaneous gastrojejunostomy: Feedings may start immediately after the procedure providing that it was performed correctly (i.e., that the tip of the catheter is beyond the ligament of Treitz. Enteral feedings must be started at low volume and low concentration to check tolerance. If the patient does not develop diarrhea (intolerance), the volume and concentration of the feeding are advanced progressively until the desired nutritional goal is reached. 6

7 CECOSTOMY DEFINITION: Percutaneous insertion of a catheter into the cecum through the anterior abdominal wall for decompression. IMAGE-GUIDANCE: Fluoroscopy. PATIENT POSITION: Supine. OPERATOR POSITION: Right side of patient. 1. General tray 2. Percutaneous sutures (Brown-Mueller T-fasteners) 3. Wires: Amplatz 0.038, 3 cm floppy tip 4. Catheters: Type Size Cope loop F Malecot F Balloon Catheter sutured to the skin. Elastikon tape for additional external fixation (mesentery). 6. Drainage bag Watch for most common complications: peritonitis is the big one here. 7

8 PERCUTANEOUS BILIARY DRAINAGE DEFINITION: Insertion of a catheter into the bile ducts for external diversion of the bile, reestablishment of bile flow into the bowel (internal-external catheter, stent placement), or for manipulations (percutaneous stone removal, biopsy, percutaneous sonography, etc) IMAGE-GUIDANCE: Sonography and fluoroscopy. PATIENT POSITION: Supine. OPERATOR POSITION: For left ducts drainage the operator is on the left side of the patient. For right-sided drainage the operator is on the right side of the patient. 1. General tray 2. Chiba 20 gauge, 10 cm length NDL Cope Wire 0, Wires: Types Size Glide Amplatz Heavy duty Catheters: Type Size Locking pigtail 8-14 Fr. PBD catheter 8-14 Fr Ring catheter 8-10 Fr. Mueller catheter 8-10 Fr 5. External Fixation: Catheter sutured to the skin. Elastikon tape for additional external fixation to the skin (mesentery). 6. Metallic stents (Wallstent are the most commonly used: 8-10 mm by mm) 7. Drainage bag 8. Baskets for gallstone removal from T-tube tract, transhepatic or transenteral (Wittich, Segura, etc.) Watch for most common complications: bleeding, pleural complications if the intercostal route is used, bile leaks, subphrenic abscess. 8

9 PERCUTANEOUS CHOLECYSTOSTOMY DEFINITION: Percutaneous placement of a catheter into the gallbladder through the abdominal wall (and selectively through the liver) for decompression of the gallbladder and selected cases of biliary obstruction, percutaneous stone removal, and transcystic manipulations. IMAGE-GUIDANCE: Sonography alone for bedside cholecystostomy, or Sonography and Fluoroscopy when performed in the interventional suite. PATIENT POSITION: Supine. OPERATOR POSITION: Right side of the patient. 1. Angio tray 2. Angiocath 16 gauge or Micropuncture set 3. Wires: Heavy duty Locking pigtail catheter 8-10 French 5. Baskets (Wittich, etc.) 6. External Fixation: Catheter sutured to the skin. Elastikon tape for additional external fixation (mesentery). 7. Collection bag Watch for most common complications: bleeding, pleural complications if the intercostal route is used, bile leaks, subphrenic abscess. 9

10 PERCUTANEOUS NEPHROSTOMY AND TRACT DILATATION DEFINITION: Percutaneous placement of catheter in the collecting system of the kidney for external diversion of urine, reestablishment of urine flow in the bladder, or dilation of the tract to allow insertion of a nephroscope for endourology manipulations. ANESTHESIA: Percutaneous nephrostomy conscious sedation (intravenous midazolam/fentanyl); for tract dilation: epidural or general anesthesia. IMAGE-GUIDANCE: Sonography and fluoroscopy. PATIENT POSITION: Patient prone or with the side in which the PN will be placed elevated 25 to 30 degrees. OPERATOR POSITION: On the same side of the kidney the nephrostomy is to be performed. 1. General tray 2. Chiba Cope wire 3. Wires: Type: Size Floppy-J Terumo Amplatz Superstiff Catheters: Type: Size PN catheter 8-14 Fr. NU stent 8-10 Fr cm Double J stents 8-10 Fr cm 5. Long dilators/sheaths Fr. 6. Ureteral connector/drainage bag 7. Microbiology/cytology/cell count of urine 8. Tract Master balloon 10 mm/10 cm 9. Amplatz dilator set (for tract dilatation only) 10. Safety catheter 5-6 Fr. 11. Malecot 24 Fr./Fr. sheath Watch for most common complications: bleeding, pleural complications if the intercostal route is used, urine leaks, catheter dislodgment. 10

11 CELIAC GANGLION BLOCK DEFINITION: Ablation of the celiac ganglia and nerve fibers to control intractable pain. Needles are placed in the celiac ganglion region and the nerve roots ablated by alcohol injection. INDICATION: Intractable solar plexus pain. Malignancy is the most common cause. IMAGE GUIDANCE: Computerized tomography. PATIENT POSITON: Supine. OPERATOR POSITION: Right side of the patient 1. Basic tray 2. Chiba needles 22 gauge, 15 cm 3. Diluted contrast (2% iodine) 4. Lidocaine 1% 5. Absolute alcohol (20-30 ml) RESULTS: Good to excellent in patients with malignant solar plexus pain, moderate to poor in patients with benign causes of solar plexus pain (i.e., chronic pancreatitits, unknown origin) Watch for most common complications: Hypotension, diarrhea. 11

12 TUMOR ABLATION DEFINITION: Tissue/tumor destruction by injection of absolute alcohol or radiofrequency. IMAGE-GUIDANCE: Sonography, sonography and computerized tomography. PATIENT POSITION: tailored to the location of the lesion. OPERATOR POSITION: On the same side of the lesion. ALCOHOL ABLATION 1. General tray 2. Needles with alcohol resistant hub: Spinal gauge 9 cm Chiba gauge 15 cm 3. Absolute alcohol (usually not more tan 10 ml/session) RADIOFREQUENCY 1. Generator 2. Needle-electrodes (Place ground pad well to avoid skin burns) Watch for most common complications: bleeding, pleural complications if the intercostal route is used, bile leaks, subphrenic abscess. 12

13 FOUR VESSEL STUDY DEFINITION: Diagnostic neuroradiology study for evaluation of intracranial circulation. INDICATIONS: Intracranial bleed, arteriovenous malformations, tumors, gamma-knife patients. IMAGE-GUIDANCE: Fluoroscopy PATIENT POSITION: Supine. OPERATOR POSITION: On the access side or at operator s preference. 1. Angiography Tray: Sterile field with bilateral groin circular openings, 4x4 gauze (small pack), towels (4), Luer lock 10 ml disposable syringes (2), Luer lock 20 ml disposable syringes (4) connecting tube, 18 g, 1.5 phlebotomy needle (1) and 25 g, 1.5 phlebotomy needle) (1), curved Kelly clamp (1). 2. Needles: 18 g single wall needle (may use micropuncture set or sheathed needle if indicated 3. Wires: 0.035, 120 cm Bentson wire (a Glide wire may be necessary on occasions) 4. 6 F Vascular sheath 5. 5 F Catheters: Pigtail (for aortic arch), Weinberg, Simmons II (normal or hydrophilic coated) TECHNIQUE ACCESS: RCFA/ LCFA (infrequently brachial access, left side is preferred) IMAGE-ACQUISITION 1. Aortic arch angiogram on 50-year-old or older patients (occasionally may be necessary in younger patients) 2. Selective R common carotid artery angiogram: anteroposterior, oblique and lateral views (both oblique projections may be used in case of obvious or suspected abnormality) 3. Selective L common carotid artery angiogram: anteroposterior, oblique and lateral views (both oblique projections may be used in case of obvious or suspected abnormality) 4. Posterior fossa imaging through selective single or bilateral vertebral artery angiograms. Watch for most common complications: Groin hematoma, stroke. 13