ULTRASOUND GUIDED PROCEDURES
Dr Qurrat-ul-AinTMO Radiology
US guided procedures
Aspiration
Drainage
Biopsy
US guided procedures
Aspirations
Cysts aspiration
Paracentesis (Ascites)
Thoracocentesis (Pleural effusion)
Cysts aspiration: Cysts are very common. Usually be diagnosed accurately with
ultrasound. In most women, they do not usually
require any intervention or follow-up.
US guided procedures
Cysts aspiration
Cyst aspirations are done when :
• Causing significant tenderness • The diagnosis of a cyst remains in question
following the ultrasound
Technique
POSITION
The patient lie on her back or slightly turned to one side with the arm placed comfortably under the head.
The skin is cleaned , numbed with topical anesthesia. Using ultrasound guidance, a small needle is advanced into the cyst and suction is applied to draw the fluid out, causing the lump to collapse.
Technique
The lump (arrow) in this patient’s right breast was thought to be a cyst, but some features are not characteristic and aspiration was necessary.
Using ultrasound guidance, a fine needle (white line) is placed so that its tip (double arrow) is in the center of the lump (single arrow). Aspiration is applied by using a syringe attached to the needle. If this is a cyst, fluid is drawn into the syringe as the lesion collapses.
After the aspiration, the needle (white line) and its tip (double arrow) are seen, but the lump is gone.
Ultrasound Guided Paracentesis
If is very helpful to get an ultrasound scan of the ascites before the procedure.
The radiologist will mark the spot for paracentesis. Two things are important:
What is the distance from the skin to the fluid? Usually 1 cm.
What is distance to the midpoint of the collection? Usually 3 cm.
Ultrasound marking and direction of Angiocath needle
Here we clearly see free fluid in Morrison's pouch that extends superiorly around the liver
See the needle entering the peritoneal cavity obliquely from just beneath the indicator marker.
Thoracocentesis (Pleural effusion)
Pleural effusion is an abnormal collection
of fluid in the pleural space. Removal of
this fluid by needle aspiration is called a
thoracoentesis.
Ultrasound Guided Technique
Patient should be sitting or in the lateral decubitus position with pleural effusion side up.
The marker on the probe should be pointed towards the head. Be sure that the transducer is perpendicular to the chest .
The diaphragm and liver or spleen should be identified first.
The probe can then be moved towards the head and from side to side to locate the largest pocket of fluid between the ribs. Once this is located a mark is made with indelible ink just above the lower rib.
The distance from the transducer to the
pleural fluid should also be noted.
The probe is then rotated 180 degrees to
visualize the pleural fluid between the ribs
to ensure that there is only fluid visualized
ie. no lung, diaphragm, or liver or spleen.
General Anatomy Pleural Effusion
Thoracocentesis can be both diagnostic and
therapeutic . Using ultrasound to guide this
procedure can decrease the very high
complication rate associated with it.
Right Pleural Effusion
Left Pleural Effusion
U/S guided p/c Abscess Drainage
Procedure allow collections which would otherwise require open surgery to be drained via a skin incision only a few mm in size.
Minimally invasive technique
Little procedure related morbidity and
equal applicability to unfit patients,
Indications
Any abnormal fluid collection which is accessible, e.g
Complicated Diverticular abscess
Crohn’s disease related abscess
Appendicular abscess
Localized abscess related to ovary (tubo-ovarian)
Abscess collection after surgery
Hepatic abscess (amebic or post-op)
Renal abscess or retro-peritoneal abscess.
Splenic abscess
Contraindications
The only common contraindications are:
Abscess is not accessible
Patient has a bleeding tendency
Technique
Abscess is first delineated &a safe route from skin to the abscess cavity is identified by ultrasound.
Prior to the catheter introduction, a diagnostic needle aspiration may also be done.
The catheter is introduced into the abscess cavity, either directly using a trocar catheter (as used for chest intubation (or by modified Seldinger’s technique using a guide-wire.
Maneuvering of the trocar or guide-wire within the abdominal cavity should be done strictly under ultrasound surveillance
Once in position, the catheter is secured
and attached to a drainage bag.
Drainage is recorded daily ,response to the
treatment is assessed by clinical
parameters & u/s.
ULTRASOUND-GUIDEDFINE-NEEDLE ASPIRATE AND BIOPSY TECHNIQUE
IndicationsIcterus/liver enzyme elevation/elevated bile acidsFocal nodules or masses anywhereRenal disease sometimes (i.e. renal dysplasia, renal masses, lymphosarcoma suspects)ProstatomegalyFree abdominal fluidCysts Lymphadenopathy
U/S guided FNA/biopsies generally not done on:
Adrenal glands Transitional cell carcinoma suspect
masses Chronic renal failure, glomerulonephritis
Probe orientationReference
marker correspondsto left side of screen
(see Screen Orientation Probe
Skin
Superficial “lesion” to biopsy
Deep “lesion” to biopsy
Rock and/or slide the probe to line up the lesion
to a “reachable” position
Deep lesion needsto be lined up
toward the edge of the beam
Superficial lesioncan be toward the edge
or in the center of the beam
Angle to use for a superficial lesion: Aim needle more perpendicular to beam
Superficial lesion FNA
Superficial lesion FNA
Superficial lesion core biopsy
Superficial lesion core biopsy
Take biopsy
Superficial lesion core biopsy
Percutaneous needle biopsy of the breast provides reliable diagnosis of both benign and malignant disease and is a proven alternative to open surgical biopsy
Breast Biopsy
Ultrasound guidance is an accurate and reliable biopsy guidance technique and is the method of choice and suitable for all breast lesions visible on ultrasound
Breast Biopsy
CNB & FNAB are effective methods for the diagnosis of most breast lesions
Although CNB has higher sensitivity &
positive predictive value for abnormalities
like micro-calcifications & distortions of
architecture.
Breast Biopsy
Breast Biopsy Indications
Focal mass or other lesion of unknown nature – palpable or non-palpable
Architectural distortion Micro-calcifications Cyst aspiration
U/S GUIDED BREAST BIOPSY PROCEDURE: The long axis of the needle, should be
visible along the long axis of the transducer. Occasionally, during an FNA biopsy or cyst
aspiration, the transducer can be rotated 90 degrees to visualize the echogenic dot of the needle within the lesion.
US Liver Biopsy
Liver biopsies are performed for both
focal and nonfocal lesions.
The primary indication for parenchymal
liver biopsy is for the diagnosis of hepatic
disease.
Indications
U/S GUIDED LIVER BIOPSY When imaging guidance is employed, it
can take one of two forms: US-guided "marking" in which a mark is
made upon the skin during US examination for a biopsy to be performed later without imaging guidance or real-time US guidance.
The patient position
The patient is positioned supine, with the
hands comfortably resting behind the
head
A preliminary US scan is performed to
identify the target and mark the skin.
The preliminary scan also ensures that no major vessels, dilated biliary channels or gall bladder are in the path of the biopsy needle.
Before the procedure is started, breathing
instructions are practiced with the patient.
performed with the breath held in expiration.
This minimize risk of injury to the pleura or lung.
The skin site is prepped and draped to
ensure asepsis The local area is
anesthetized with a local anesthetic.
The cutting needle is then fired with US
documentation of the site.
KIDNEY BIOPSY
Indications:
Biopsy of a focal solid lesion /suspicious
cystic lesion for diagnosis.
Nonfocal biopsy to evaluate for
nephropathy or renal transplant rejection
US has the advantages of real-time needle
placement
No radiation & is therefore well suited for most
nonfocal renal biopsies in thin pts and in
biopsies of some focal solid masses or cystic
masses .
Procedure Technique
The patient is placed in the prone position and the biopsy is typically taken from the lower pole of the kidney if there are no specific locations of interest.
The biopsy needle is guided using ultrasound to ensure visualization of the needle as it pierces the kidney parenchyma.
Care is taken not to enter the collecting system (as it would result in haematuria) or to go near the renal hilum (to prevent injury to the vessels).
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