Blood path technique to reduce pneumothorax after CT guided lung biopsy Poster No.: C-0753 Congress: ECR 2011 Type: Scientific Paper Authors: G. J. Mallarajapatna, N. Ramanna; Bangalore/IN Keywords: Interventional non-vascular, CT, Biopsy, Hemorrhage DOI: 10.1594/ecr2011/C-0753 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 17
Purpose To evaluate a new technique of percutaneous lung biopsy / procedure under CT scan guidance to assess its efficacy in reducing the incidence of post biopsy/ procedure pneumothorax. Images for this section: Fig. 1: Post-biopsy pneumothorax in a patient with right lower lobe mass. The procedure was performed before the 'NEW TECHNIQUE' was used at our institute. Page 2 of 17
Methods and Materials Total of 22 patients 20 underwent biopsy of lung mass 2 underwent gold fiducial placement for stereotactic radiosurgery (CyberKnife) treatment of lung nodules. Biopsy patients: 19G co-axial needle is advanced till the outer surface of pleura and check CT scan performed to confirm right direction of the needle and assessing exact distance to be traversed further. Needle is introduced very fast to the target lesion and check scan is again performed to confirm accurate positioning of the needle. Multiple cores of biopsy are taken using a 20G semi-automated gun introduced through the coaxial needle by slightly changing the ditection of the needle. Fiducial placement: Similar to above. However, no check scans are taken. Instead, two points of entry are marked and 18G needles are introduced. Fiducials are introduced through these needles one each in both needles. Both the needles are withdrawn for about 2 to 3 cm and again one each fiducials are introduced through both the needles in their new position. At least 4 fiducials are placed in and around the lung lesion to be treated by CyberKnife. All patients are placed in puncture site dependant position immediately after the needles are withdrawn out of patients body. Check CT scans taken immediately after the procedure to rule out any pneumothorax. Patients observed for 1 to 2 hours and sent home with instructions (to report immediately if any new chest pain and/or breathlessness developed) Images for this section: Page 3 of 17
Fig. 1: needle tip outside pleural surface and the direction and distance to the target lesion in left lung adjacent to mediastinum are confirmed and assessed respectively. Fig. 2: needle tip in place immediately after rapidly traversing the needle through the lung into the lesion Page 4 of 17
Fig. 3: needle tip outside the pleura. A pulmonary lesion is noted in a higher section (not shown) Page 5 of 17
Fig. 4: Needle tip outside the pleural surface. Both the direction and the distance to the target lesion in right lung are confirmed and assessed respectively. Page 6 of 17
Fig. 5: Needle tip in place after RAPIDLY traversing the normal lung to reach the target. Page 7 of 17
Fig. 6: Needle tip outside the pleural surface. Both the direction and the distance to the target lesion in lower lobe of right lung are confirmed and assessed respectively. Page 8 of 17
Fig. 7: Needle tip in place after SWIFTLY passing through the normally aerated lung parenchyma into the target lesion. Page 9 of 17
Results Needle track hemorrhage - in all patients (100%) Self limiting hemoptysis - in all patients (100%). None developed significant pneumothorax (0%). One patient (4.5%) developed a small pneumothorax (less than 3 mm) which did not increase and was treated conservatively. A comparison of one of the studies (n = 100) included in the reference --- in which pneumothorax developed in 23% of patients as below... 4 of the 23 patients (17%) with pleural lesions 19 of the 77 patients (24%) with deep lesions. Pneumothorax occurred in four of the 45 patients (9%) who had deep lesions and received autologous blood clot and in 15 of the 32 patients (47%) who had deep lesions and did not receive autologous blood clot (P <.001). In patients with emphysema, pneumothorax occurred in three of the 20 patients (15%) who received autologous blood clot and 10 of the 14 (71%) who did not (P <.001). Seven (7%)large pneumothoraces necessitating treatment; all in patients who did not receive autologous blood clot (14%). Images for this section: Page 10 of 17
Fig. 1: needle track hemorrhage immediate post biopsy Page 11 of 17
Fig. 2: Needle track hemorrhage immediately after the needle is removed after gold fiducial insertion for CyberKnife treatment Fig. 3: Immediate postbiopsy, the patient was placed in right laterla decubitus position for about 10 minutes and then transferred to supine position. Check CT scan demonstrates needle track hemorrhage well. Page 12 of 17
Fig. 4: Immediate post biopsy scan with patient in supine(puncture site dependant)position, demonstrating needle track hemorrhage and no evidence of significant pneumothorax. Page 13 of 17
Conclusion Rapid passage of needle causes tearing of some of the smaller vessels along the needle track resulting in needle track hemorrhage (blood path) Puncture site dependant position appears to seal the pleural rent caused by the needle. Analogous to the earlier described autologous blood clot seal (ABCS) technique. We conclude the speed of needle movement (of course, with, immediate post-biopsy puncture site dependant position) is crucial as vessels may be displaced by a relatively slow moving needle. The benifit is even more conspicuous when we consider the previous incidence of pneumothorax at our institute, which was 20% and 6% (total and significant respectively) prior to the practice of this new technique. Images for this section: Page 14 of 17
Fig. 1: All our patients demonstrated track hemorrhage when the rapid insertion rechnique was used with self limiting hemoptysis. So, can we call it BLOOD PATH TECHNIQUE? -- similar to autologous blood clot seal technique!!!!! Page 15 of 17
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Personal Information Dr. Govindarajan Janardan Mallarajapatna, MBBS, MD. Consultant - Diagnostic and Interventional Oncoradiologist. Health Care Global - Bangalore Institute of Oncology, Bangalore, India. Email: revathigovind@gmail.com Ph: +91 9916027801 Page 17 of 17