INTERVENTIONAL RADIOLOGDR M.KILANI,MD,LILLE,FRANCE

ULTRASOUND & CT

Puncture sitesPuncture sites

Access:

•Meticulous guiding ultrasound exam.

- Shortest skin-target distance

- Avoid blood vessels, biliary tree, bowel

- Use Doppler may be helpful- Use Doppler may be helpful

- Once access decided:

Test respiratory training (deep or shallow) with short apnea to simulate

biopsy moment

Advantages of US:

- Real-time visualisation of the target.

-Good visualisation of the access window.

- Real-time progression of the needle with possible modification of the trajectory.

Interventional Ultrasound

�Always Avoid

�Large vessels,

proximal organ vessels

�AVOID IF POSSIBLE

�Bowel

Liverproximal organ vessels

�Ureter!

�Gallbladder

�Parenchymatous

organs:kidney, spleen,

pancreas

�Liver

�Distal vessels

CONDITIONS OF REALISATIONCONDITIONS OF REALISATION

One day HospitalizationAmbulatory (if cooperative, family at home, classical technique)

FastingClinical and imaging data

- platelets >150 000- PT >70 %s- TCA < 2x Normal- TCA < 2x Normal

Stop anticoagulant TTT 8 days before.

Sédation - anxiolytic 2 hrs beforeNo sleeping patient!!

ULTRASOUNDULTRASOUND

�Cleaning of probe, keyboard and cable (protocole).

�Select probe and application depending on procedure �Select probe and application depending on procedure

�(Try to choose sectorial view if linear probe is used)

�

INTERVENTIONAL PROCEDUREINTERVENTIONAL PROCEDURE

Skin antispetic measures by technician according to

protocol

Patient covered with sterile field

Sterile material on sterile table

Cover the US probe with sterile protection

�Local Anesthesia (10 à 20 cc Lidocaïne 1%)

IM or LP needle according to depth of the target

- Evaluation of the trajectory

- Take care of air in the syringe!

- If liver biopsy go to capsule

INTERVENTIONAL PROCEDURE

�Needle guide (US/TDM)

anesthesia

�Skin deep incision with scalpel axis //ribs (intercostal artery)

GUIDANCE METHOD GUIDANCE METHOD

Biopsy Kit :

Adaptable systeme on the probe: visualization of target and needle trajectory

“ Free-hand” Technique :

Probe is positioned at the entry point with needle along axis of US beam allowing visualisation of the whole length of the trajectory (abdominal).

Always visualize your entry path

with real-time needle progression

GUIDANCE METHOD

��hand techniquehand technique--FreeFreepreferpreferAlwaysAlwayspossibility of orientation adjustment

at last minute and angle of skin penetration. Once capsule is

traversed no more adjustmentpossible: withdraw and redress yourpossible: withdraw and redress your

angle

�Needle aligned in the axis of US beam to visualize its swhole length

�If you loose trajectory move probe 1 or 2 degrees/ needle then scree with

probe in Doppler mode to searchneedle

GUIDANCE METHOD

��hand hand --FreeFreepreferpreferAlwaysAlwaystechniquetechnique

�Needle aligned in the axis of US beam to visualize its swhole length

�If you loose trajectory move probe 1 or 2 degrees/ needle then scree withor 2 degrees/ needle then scree with

probe in Doppler mode to searchneedle

Interventional Ultrasound

Lateral decubitus

Intercostal approach! Scalpel Orientation when doing skin incision

NeedlesNeedles

Many varieties

Different sizes, calibers, form, shape and nature of the procedureDifferent sizes, calibers, form, shape and nature of the procedure

• Cytology : Chiba needle, Franseen

• Histology : Bard needle

NeedlesNeedles

Many varieties

Interventional Ultrasound

�If solid mass : biopsy 18/16 G ‘True cut’

�If cystic mass : initial Fine Needle Aspiration

(FNA)-Don’t empty-wall biopsy

�If possible do microbiopsy (histology) of the �If possible do microbiopsy (histology) of the

wall

‘Co-axial’ Technique

�2 types : co-axial - tandem

�Coaxial : 1 large bore needle (19G) in contact with the lesion ; multiple samples taken with smaller and longer needle inserted

within it (20G)within it (20G)

Advantage : One puncture with multiple samples (<hemorragic risk but only one direction)

�Tandem : 1 needle in the lesion ; biopsy needle parallel

Advantage : trajectory already done and multiple directions of biopsy

Interventional Ultrasound

�Automatic needle: one action movement

�Progression with needle tip visualisation during

apneaapnea

�Adjust needle length

If gun is used consider length of specimen

(wall/necrosis)

�Specimens 3

�Change needle (FNA / microbiopsy) depending on

tissue obtained•Biopsy of normal liver also

Liver

�Increased hemorragic risk if hemangioma puncture

�Fill the needle track with Gelfoam

Interventional Ultrasound

�Possible puncture of distal portal or hepatic branches

�Biopsy subcapsular lesion by penetration through normal liver.

�Use respiration to move the diaphragm and keep away the pleuram recess from the needle to get below it

�Coaxial Technique

GUERIDON PRELEVEMENTGUERIDON PRELEVEMENT

�Sterile table

�1 gauze

�1 ampoule of normal saline (moisten biopsy)

�1 bottle of Formol or wet gauze

�If drainage : tubes of bacteriology for culture & sensitivity

DEALING WITH SPECIMENSDEALING WITH SPECIMENS

BIOPSIES LIVER KIDNEY LYMPH NODES PANCREAS OR ABDOMINAL MASS:

�place on gauze then wet with normal saline (during puncture)time :st1

�.formolPlace in time :nd2

FNA OR COLLECTION DRAINAGE :

�Aspiration with syringe then put aspirate in sterile tube for bacteriological studies.

COMPLICATIONSCOMPLICATIONS

Complications are rare (0,008% à 0,03 %)

-Vasovagal attack

Severe complicationsSevere complications

- hemorrhage, arterio-veinous fistula, hematoma andpneumoperitoneum (liver)

- Acute pancreatitis if normal pancreatic tissue

- Metastatic seeding of the needle track.