Single-Step Placement of a Self-Retaining Accordion Catheter

Transcription

1 337 J. G. Caridi1 I. F. Hawkins, Jr. M. C. Hawkins Received August 1 6, 1982; accepted after revision February 10, All authors: Department of Radiology (Box J- 374), University of Florida College of Medicine and Shands Teaching Hospital, Gainesville, FL Address reprint requests to I. F. Hawkins, Jr. AJR 143: , August X/84/ C American Roentgen Ray Society Single-Step Placement of a Self-Retaining Accordion Catheter The accordion catheter was developed as an adjunct to the Hawkins needle guide to provide safe single-step percutaneous drainage. The Hawkins needle guide is a long, 22-gauge skinny needle-cannula system that can be used like any other skinny needle. It can also be used for drainage catheter placement. The accordion catheter is a 6.5 French Teflon catheter with a sigmoid tip. With the use of monofilament, the sigmoid tip can be retracted into a T configuration to prevent dislodgment. The 22- gauge needle guide, preloaded with an accordion catheter, can be manipulated safely while the drainage target is located. Then the accordion catheter can be advanced into the target over the needle guide. The accordion is easily formed, even in small targets. Successful drainage was achieved in 127 of 131 drainage procedures in which this technique was used. Sepsis did not occur as a complication in any of these procedures. For the past 5 years, we have used the 22-gauge needle guide [1] for virtually all percutaneous procedures in which the possibility of catheter placement was considered. The needle guide serves as both a needle and a guide wire. It can be preloaded with a variety of catheters, and multiple passes can be made safely because of its small size. After the target is entered, the catheter is simply slid into the target oven the needle guide. Initially, we used a preloaded 4 French catheter; this was exchanged for a preloaded 5 French catheter, and by using an end-hole dilating guide wire [2], an even larger, definitive drainage catheter could be placed. The current system eliminates the need for catheter exchange by using a 6.5 French Teflon self-retaining accordion catheter (Cook, Bloomington, IN), which is placed in a single step after the drainage target has been located with the needle guide [3]. Equipment and Technique The accordion catheter is a 6.5 French Teflon catheter with the distal tip in a sigmoid configuration. It has a inch (0.71 mm) end hole to fit the needle guide snugly (fig. 1). For drainage, the catheter also has multiple side holes throughout its sigmoid part. In addition, there is a inch (1.02 mm) side hole at the proximal sigmoid curve, which permits catheter guide wire exchanges using a inch (0.89 mm) guide wire. This side hole is also used to transport a monofilament. The monofilament is strung through the sigmoid tip in a manner that results in a T configuration when the monofilament is retracted (fig. 1 ). The monofilament is secured by a Tuohy-Borst fitting with a notch in the hub. After the monofilament is retracted, the Tuohy-Borst fitting is tightened. The monofilament is then secured and a knot is tied (fig. 2). The accordion catheter is preloaded on the proximal end of the needle guide, leaving the distal part of the needle guide free to enter the target. When the target is presumably located, a small amount of fluid can be aspirated or a very small amount of contrast material can be administered to confirm the position. A inch (0.46 mm) mandrel guide (Cook) is then advanced into the target (fig. 3A). The torque capabilities of this guide allow it to be maneuvered into a ureter, distal common bile duct, or large abscess cavity, depending on the situation. The 22-gauge flexible needle guide is then advanced over the smooth steel

2 338 CARIDI ET AL. AJR:143, August 1984 LIEI-7 Fig. 1 - Accordion catheter loaded on needle guide (top) with monofilament strung through sigmoid tip of catheter(center). Bottom, Tuohy-Borst sidearm fitting secures retracted monofilament, which results in T configuration of catheter s tip. MONOFILAMENT.-. RETRACTED S\\ AND HUB 4TlGHTENED MONOFILAMENT ln WEDGED.. SLOT KNOT TIED TO LOCK Fig. 2.-Technique for securing monofilament with Tuohy-Borst flthng. section of the mandrel guide deeper into the target (fig. 3B). If the needle guide will not slide over the mandrel, the two can be advanced as a unit. This inch (0.46 mm)-22-gauge complex serves as a very stiff guide wire, much stiffer than the standard inch (0.97 mm) guide wire. Once this complex is secured within the target, the accordion catheter is simply slid forward, just as with a standard exchange guide wire (fig. 3C). Then the monofilament is retracted (fig. 3D). When the accordion catheter is advanced, it must be positioned deep within the target. A mark on the needle-guide cannula will indicate when the most proximal side holes have advanced beyond the tip of the needle. If the proximal side holes are outside the target area, retracting the monofilament will result in dislodgment of the catheter tip. Suboptimal placement of the needle guide will preclude placement of the accordion catheter. This may occur with inaccurate target access or placement within a small calix, biliary radicle, or abscess loculation. In such cases, the hub of the needle can be removed along with the accordion catheter. A 4 French catheter is then advanced over the needle guide and maneuvered (with torque wires, etc.) to the optimal position. The 4 French catheter is removed and the accordion catheter is replaced over the needle guide in a more secure position. For removal or exchange of the accordion catheter, the monofilament is cut and removed (fig. 4). After removal of the monofilament, either a inch (0.64 mm) or inch (0.89 mm) guide wire can be used for the exchange. The inch guide wire will exit at either the tip or the larger proximal side hole. If the inch guide wire is used, it will be able to exit only through the most proximal ( inch [1.02 mm]) side hole. If the monofilament cannot be removed, the free ends are secured and a inch (0.64 mm) Lunderquist exchange wire [4] or a needle guide is used to exchange for a larger catheter. A B C D Fig. 3.-Insertion of accordion catheter into tubular structure: A, Needle guide (preloaded with catheter) and inch (0.46 mm) mandrel guide are advanced to target area; B, 22-gauge flexible needle guide is advanced over mandrel guide, providing stift coaxial guide complex for catheter; C, accordion catheter is advanced until most proximal side holes are within target; D, monofilament is retracted, forming T configuration. Experience and Results We have used the accordion catheter in more than 131 procedures over a 2-year period. It was used for drainage of the biliary tree before definitive cholangiography and manipulation in 34 cases, of which 14 were in nondilated systems. Sixty-four nephnostomies have been performed using the accordion: In most of these, the catheter was used to relieve hydronephrosis in obstructed systems; however, in eight cases the catheter was placed into the nondilated pelvis for percutaneous stone removal or stricture dilatation. The accordion was used as a primary drainage catheter in 1 6 abscesses (four psoas, seven hepatic, three abdominal, and one each pancreatic and post-renal transplant), 1 3 gallbladdens (for cholecystitis), and one renal and one hepatic cyst. It was used in patients of all ages, including two neonates and two adolescents. Successful access to the biliany tree was achieved in 34 (94%) of 36 attempted biliary drainage procedures. The two unsuccessful attempts were in nondilated systems in which

3 AJR:143, August 1984 SINGLE-STEP ACCORDION CATHETER 339 the needle guide opacified tiny biliary radicles that were too small to permit insertion of the accordion. In most cases, the angle of entry was adequate to permit placement of the accordion catheter without opacifying the system and requiring additional passes. All of the biliary catheters remained in place for the desired duration without premature dislodgment. No sepsis on hemorrhage occurred. Of the 64 nephrostomies, 59 (92%) were performed by one-step catheter placement. The other five kidneys required successive dilatation of the renal parenchyma with 4 and 5 French dilators. In three of these, multiple surgical procedures had been performed. The other two kidneys were in a patient with longstanding neunogenic bladder and bilateral reflux. Five Fig. 4.-Removal of accordion catheter and exchange over standard inch (0.089 mm) guide wire. of the nephrostomy catheters were dislodged prematurely: One, placed in a neonate, was dislodged after 2 weeks from an unknown cause; another was inadvertently removed by nursing staff during a dressing change; one patient snagged the catheter on a piece of furniture; and another patient, with reduced mental status, pulled the catheter out twice. No sepsis or hemorrhage occurred. In the 1 3 gallbladders in which the catheter was used for drainage of cholecystitis, success was achieved in all but one. In this case, the gallbladder was located with sonography, and the accordion catheter was placed without fluoroscopic control. Initial drainage was achieved, but side holes outside the gallbladder led to leakage and eventual surgery. The procedure did confirm the suspected diagnosis of acute cholecystitis, and the patient underwent uneventful cholecystectomy. Access to the 1 6 abscesses (fig. 5) as well as a hepatic and a renal cyst was achieved by the one-step, single-pass method. The accordion catheter was adequate for drainage in all but one very large hepatic abscess, which required larger drainage catheters. In four recent cases, we used acetylcysteine to liquefy the purulent material; this resulted in excellent drainage with the relatively small 6.5 French catheter despite complex cavities and viscous contents. In none of the various procedures have encrustations and occlusions of the catheters occurred, which would have precipitated premature removal or replacement. However, three nephrostomy catheters required replacement after about 4 months because of kinking. No catheter transections have occurred. Discussion The concept of the accordion catheter evolved from our experience with a modified Cope loop self-retaining catheter [4-6]. Since we have found that one-third of the straight on pigtail catheters were dislodged from the biliany tree or urinary tract within a few hours to months, we have insisted on using self-retaining catheters for the past 4 years. Unfortunately, Fig. 5.-Accordion catheter draining large lumbar abscess. Fig. 6.-A. Biliary drainage before cholangiography. Catheter is placed in nonddated intrahepatic duct. Small amount of contrast material is injected (arrows) to confirm position. B, Cholangiogram obtained after 24 hr of extemal drainage. Total obstruction.

4 340 CARIDI ET AL. AJR:143, August 1984 even if a catheter is anchored very securely to the skin, organ motion often dislodges the tip from the target. We found that by inserting a 6.5 French Teflon retention catheter, the mcidence of dislodgment was markedly reduced. However, the system that we were using (6.5 Teflon Cope loop) [4, 5] required several catheter exchanges, and the Cope loop was somewhat difficult to form in tubular structures such as the biliary tree. The accordion catheter T configuration can be produced more easily than the Cope loop in small structures. Since straight or even pigtail catheters often become dislodged, we believe that in any situation where there is even partial obstruction, a retention catheter should be employed. In the biliary system, we have experienced a low rate of sepsis by insisting on 24-hr drainage of the biliary tree before cholangiognaphy or catheter manipulation is performed (fig. 6). In over 1 50 cases of percutaneous transhepatic cholangiography and drainage, we have encountered no cases of septic shock. The accordion will form in both dilated and nondilated biliany trees above the obstruction or stricture, permitting drainage until a definitive procedure can be performed. In 14 of the nondilated biliary systems, this configuration was critical in permitting placement of a retention catheter. We believe that searching for the target with a 22-gauge needle and immediately placing the drainage catheter over the needle guide reduces the trauma and, in turn, bleeding and sepsis that can occur with larger needles and catheten/ guide-wire exchanges. Even when aiming at large targets, vital structures can be entered inadvertently. The large or small bowel was entered in one patient during an attempt to drain the gallbladderfon acute cholecystitis and in two patients during abscess drainage attempts. In each case, the needle guide was redirected in the target, and the accordion catheter was replaced without the complications (e.g., peritonitis) that may have occurred had the organ been entered using a largebore needle. The single-step placement also reduces the spillage that can occur in multiple catheter/guide-wire exchanges. This is particularly important in drainage of acute cholecystitis and abscesses, where contamination can result in peritonitis (chemical and bacterial). The ability to slide the 22-gauge needle guide over the inch (0.46 mm) mandrel guide deep into the target provides a very stiff, safe guide wire that permits simple placement of the accordion catheter or any other catheter, providing that the tip fits the cannula tightly. In only five cases in which the target was very fibrotic or calcified, was a smaller dilator required before definitive accordion-catheter placement. Initially, we used the accordion catheter for hr decompression, after which it was exchanged for a larger drainage catheter. Although others have advocated large-bore drainage catheters [7], we have found both the 6.5 French modified Cope loop and the accordion catheter to be adequate for draining all types of cavities, even on a long-term basis, with the exception of one very large hepatic abscess. The addition of acetylcysteine (Mucomyst) [8], which liquefies the punulent material, has facilitated drainage with the relatively small 6.5 French Teflon catheter. Even large cavities with very thick purulent material have been drained effectively. In rnultiloculated abscesses, several accordion catheters can be placed with relatively little trauma. The commercially available newer Cope loop catheters are softer and more durable than the Teflon catheters. However, we noticed that these newer catheters became encrusted quite easily in several nephrostomy patients. In three cases, encrustation occurred with the newer Cope loop catheters but not with the 6.5 French Teflon catheters, which were in place for up to 6 months. Apparently, the Teflon material is smoother and does not allow precipitation of the chemicals as readily as the newer polymers. The catheter should always be anchored at the skin with sufficient length of catheter in the target to permit organ excursion during breathing or change of position; otherwise, the accordion catheter may be retracted into the wall of the target. The self-retaining catheters definitely reduce the mcidence of dislodgment due to organ motion; however, the problem of forceful removal by disoriented patients or entanglement or snagging by surrounding objects still occurs. We are currently developing a circumferential belt apparatus that can be attached to the catheter for prevention of dislodgment in such circumstances. REFERENCES 1. Hawkins IF Jr. New fine needle in cholangiography with optimal sheath for decompression. Radiology 1979;131 : Andrews R, Paige A, Hawkins IF Jr. Catheter end-hole dilating guide wire. AJR 1982;1 39: Hawkins IF Jr, Hawkins MC, Nanni GS, Andrews RC, LeGrand E. Use of needle guide including a new single-step accordion catheter and a new exchange guide. Certificate of Merit scientific exhibit, presented at the meeting of the American Roentgen Ray Society, Atlanta, April Andrews RC, Hawkins IF. The Hawkins needle-guide system for percutaneous catheterization: 1. Instrumentation and procedure. AIR 1984;142: Andrews AC, Hawkins IF, Vogel 5G. The Hawkins needle-guide system for percutaneous catheterization: 2. Clinical experience in the biliary tract and abscess drainage. AiR 1984;1 42: Cope C. Improved anchoring of nephrostomy catheters: loop technique. AiR 1980;135: vansonnenbeng E, Ferrucci JT Jr, Mueller PR, Wittenberg J, Simeone JF. Percutaneous drainage of abscesses and fluid collections: technique, results and applications. Radiology 1982;142: vanwaes PFGM, Feldberg MAM, Mali WPTM, et al. Management of loculated abscesses that are difficult to drain: a new approach. Radiology 1983:147:57-63

5 This article has been cited by: 1. E.M. Paul, R. Marcovich, B.R. Lee, A.D. Smith Choosing the ideal nephrostomy tube. BJU International 92:7, [CrossRef] 2. IRVIN F. HAWKINS, E. WILLIAM AKINS, RICHARD J. PRY, ROY J. SIRAGUSA, JAMES J. GARNER, RUSSELL LOCKE, IRA W. KLIMBERG Combined Retrograde/Antegrade Nephrostomy Technique. Journal of Endourology 1:4, [CrossRef] 3. Suzanne Klimberg, Irvin Hawkins, Stephen B. Vogel Percutaneous cholecystostomy for acute cholecystitis in high-risk patients. The American Journal of Surgery 153:1, [CrossRef]