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ab
cd
ab
Fig. 36.8 USG-guided
FNAB of laryngeal mass. For
a 52-year-old patient with a
mass in the glottis and
supraglottis, a biopsy
attempted twice via direct
laryngoscopy was negative.
On USG, a heterogenous
mass (asterisk in a) is seen in
the glottis and supraglottis
with erosion of thyroid lamina
and resultant extralaryngeal
extension (asterisk in b).
Extralaryngeal extension of
the lesion was targeted under
USG.A 22G needle was
inserted under USG guidance
(arrow in c) and a nal needle
aspiration biopsy was done.
Biopsy revealed squamous
cell carcinoma
S. Sharma et al.
Fig. 36.9 USG-guided
FNAC of thyroid lesion.
Post-left hemithyroidectomy
case of follicular variant of
papillary carcinoma of the
thyroid. An isoechoic solid
taller than a wider lesion
(asterisk in a) with smooth
margins is seen in the right
lobe of the thyroid gland with
no calcication. On color
Doppler (b), the lesion shows
vascularity within the lesion.
Image c shows needle
insertion (arrow in c) under
USG guidance followed by
FNAC from the lesion
c
36 Nonvascular Inter ventions ofHead andNeck
455
To conclude, ultrasound is the primary modality used to
guide sampling of the supercial head and neck lesions with
minimal patient risk and excellent tissue sampling.
36.5 Ultrasound-Guided Percutaneous
Drainage ofHead andNeck Abscess
Deep head and neck infection with abscess formation is a potential complication following upper respiratory tract and odontogenic infections in children and adults. Due to anatomic
localization of vital structures in head and neck, emergent treatment of abscess is imperative. Antibiotics alone or in combination with surgical drainage are routinely used for management of
abscess. Surgical drainage is usually done under general anesthesia and is associated with signicant disadvantages like cosmetically unpleasant scars and potential risk of neuro-vascular injury.
Ultrasound-guided drainage of head and neck abscess is a
minimally invasive, cost-effective technique and is gaining
popularity for management. It is very effective in draining
deep neck infections without recurrence and with minimal to
nil risk to neurovascular structures of head and neck. Needle
aspiration with a wide bore needle (14/16/18G) can be done
in small volume abscess or a pig-tail drainage can be done if
the abscess is large [16, 31].
treatment is covered in detail in chapter on vascular interventions in head and neck.
36.5.2 Percutaneous Sclerotherapy ofHead
andNeck Low-Flow Vascular
Malformations andCystic Lesions
Image-guided sclerotherapy is a less invasive and relatively
safe percutaneous technique for the treatment of low-ow
vascular malformations and cystic lesions of the head and
neck. This technique is particularly useful for poorly dened
transpatial vascular malformations close to vital structures
where complete surgical resection is technically challenging
and the risk of injury to adjacent structures is high.
Sclerotherapy in cystic lesions like thyroglossal duct cyst,
branchial cleft cyst, ranulas, and benign thyroid cysts is less
frequently used and surgery remains the rst line of treatment. Epithelial-lined cystic lesions are pathologically distinct from endothelial-lined vascular malformations and
reports of the use of sclerotherapy for treatment are limited
and need further validation.
36.6 Radiofrequency Ablation ofHead
andNeck Tumors
36.5.1 Interventional Radiology inVascular
Malformations
Interventional radiology plays a key role in the management of
vascular malformations of head and neck. Detailed knowledge
of head and neck anatomy, potential site involved, and associated specic complications is required before treating any vascular malformation. Broadly the malformations are classied
as being low ow or high ow depending on the absence or
presence of arterial feeders. Understanding ISSVA classication and its management implications is imperative before
treating any vascular malformation. The classication is covered in the chapter on vascular malformations.
Pre-treatment dynamic MRI is essential to understand the
nature of vascular malformation and vascular feeders if any.
Low-ow malformations are treated with percutaneous
sclerotherapy while the high-ow ones are treated with
endovascular embolization. High ow malformations and its
Malignant tumors of the head and neck region account
for a significant number of cases in the elderly population. Advanced head and neck malignant tumors are notorious for recurrence and have low 5-year survival rates.
Despite the best palliative care and treatment, patients
suffer from disease and treatment morbidity with low
quality of life. Treatment options for advanced or recurrent head and neck tumors are often challenging owing to
the proximity of multiple adjacent vital structures in the
head and neck.
Radiofrequency ablation is a promising alternative for the
palliative treatment of advanced head and neck tumors with
minimal complications. The procedure is performed under
GA and the patient can be discharged the next day. Placement
of the RFA probe into the tumor is guided by USG or
CT.Immediate response in pain is noted following RFA with
a reduction in the bulk of tumor. RFA has proven effective
inlocal control of disease and thus improving quality of life
456
S. Sharma et al.
in end-stage head and neck malignancies where standard
curative treatment is not an option [10, 16, 32].
36.7 Conclusion
Image-guided sampling is an established technique in the
head and neck region with USG being preferred for supercial locations like thyroid, parotid, and supercial cervical lymph nodes whereas CT guidance is used for
deep-seated lesions. USG-guided drainage of deep-seated
head and neck abscesses is a minimally invasive, costeffective technique, and is gaining popularity for
management.
Percutaneous sclerotherapy under USG guidance is used
widely for low-ow vascular malformations.
RFA in advanced and recurrent head and neck malignancies has proven effective in local control of disease and
improving quality of life where standard curative treatment
has failed.
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Nonvascular Thoracic Interventions
AbhishekJayant, AshuSeithBhalla, PriyankaNaranje,
andIshanGupta
37
Key Messages
1. Image-guided thoracic non-vascular procedures include
predominantly transthoracic FNACs/Biopsies, percutaneous drainage procedures and lung tumour ablation.
2. Thoracocentesis can be performed for diagnostic purposes or for therapeutic purposes for both air and uid
removal using small bore needles and pigtail drainage
catheters.
3. USG and CT guidance are helpful in safe and accurate
access and catheter placements for drainage.
4. The primary indication for intrapleural brinolytic therapy is empyema that is unlikely to completely resolve
just with tube thoracostomy due to loculations and brin
deposition, resulting in non-expansion of the underlying
lung.
5. Various agents that can be used for intrapleural brinolysis are streptokinase, urokinase, recombinant tissue
plasminogen activator (rtPA) and DNase.
6. Indwelling pleural catheter (IPC) is considered in
patients in whom the pleural effusions are expected to
reaccumulate in a short time such as in malignant effusions. The subcutaneous tunnel helps to secure the catheter with less risk of secondary infection.
7. CT-guided drainage using Seldinger technique for catheter placement can be done in cases of mediastinal collections and lung abscesses for patients not responding
to medical therapy.
8. According to the Society of Interventional Radiology
(SIR) consensus guidelines for the periprocedural management of thrombotic and bleeding risk in patients
undergoing percutaneous image-guided interventions,
percutaneous lung biopsy is classied as a high bleeding
risk procedure. For such procedures, INR and platelets
should be ≤1.5 and ≥ 50,000/μL, respectively.
Clopidogrel should be withheld 5days prior to the procedure, and aspirin should be withheld 3–5days before
the procedure.
9. For CT-guided lung lesion biopsy, the access site should
be chosen in such a way that it traverses the least amount
of aerated lung and avoids emphysematous lung, bullae,
ssure and major bronchi and vessels.
10. Pneumothorax is the most common complication of percutaneous lung biopsy. Most of them are small with only
a few requiring chest tube drainages. Other complications include pulmonary haemorrhage, air embolism and
tumour seeding.
11. CT-guided radiofrequency ablation (RFA) is a safe and
effective treatment option for lung cancer, especially
lung metastasis up to 2cm in patients who are not surgically t.
37.1 Introduction
Non-vascular thoracic interventions are frequently performed in IR procedures. The various non-vascular thoracic
interventions include various diagnostic and therapeutic procedures such as pleural uid tapping, biopsy, drainage, ablation, etc. The vascular interventions of the thorax are covered
in Chap. 19.
37.2 Thoracic Drainage Procedures
A. Jayant · I. Gupta
Fellow Thoracic Radiology, Department of Radiodiagnosis and
Interventional Radiology, All India Institute of Medical Sciences,
Delhi, India
A. S. Bhalla (
Department of Radiodiagnosis and Interventional Radiology,
All India Institute of Medical Sciences, Delhi, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_37
*) · P. Naranje
Pleural and mediastinal compartments are potential spaces
where uid and/or air can accumulate resulting in impairment of respiratory and cardiovascular function. The nature
of uid can be transudative, exudative, haemorrhagic or
purulent. If uid is purulent in nature it can contribute to
sepsis and the age-old principle of “pus anywhere in the
459
460
A. Jayant et al.
body requires drainage” should be followed. Accordingly,
image-guided procedures are aimed at establishing the nature
of uid by thoracentesis and providing therapeutic drainage
by a percutaneous catheter system.
37.2.1 Pre-Procedure Evaluation
Medication Check Including Antiplatelets and
Anticoagulation
Elective Pleural Procedures
For those with a high risk of thrombosis (e.g., coronary
stents), multidisciplinary team discussion may be required.
In cases of elective procedures, the following recommendations are followed:
• Warfarin should be stopped 5days before the procedure,
and pre-procedure INR should be ≤1.5.
• Direct oral anticoagulant medication (DOAC) should be
withheld 24–48 hours before the procedure and be
resumed 24 hours after a low-risk procedure and
48–72hours after a high-risk procedure. For patients at
high risk of venous thrombosis, daily prophylactic hepa-
rin should be considered prior to restarting the DOAC.
• Clopidogrel and prasugrel should be withheld 5 days
prior to the elective procedure. For Ticagrelor, the dura-
tion should be 7days pre-procedure.
• Aspirin therapy can be continued.
• Phosphodiesterase inhibitors such as dipyridamole should
be withheld at least 24 hours before a high-risk
procedure.
Emergency Pleural Procedures
Any bleeding risk should be corrected wherever it is practical while in complex situations, input from haematologist
may be required.
Coagulation prole evaluation is not mandatory, if there
is no known history of coagulopathy and the patient is not on
any anticoagulant medication [1–6].
37.2.2 Imaging
lung, the presence of emphysematous bullae or where sonographic views are not optimal, like posteriorly loculated
pleural collections.
37.3 Thoracocentesis
Thoracocentesis can be performed for diagnostic (~50ml) or
therapeutic (~500–1500ml) purposes depending on the indication and amount of uid removed.
37.3.1 Indications
Pneumothorax
• Primary or secondary spontaneous pneumothorax
Pleural effusion
• Diagnostic tap
• Large volume aspiration to relieve patient’s symptoms,
particularly shortness of breath
• For assessment of underlying non-expandable lung
37.3.2 Relative Contraindications
• Coagulopathy or concurrent anti-coagulation treatment
• Local infection at the site of puncture
• Pneumothorax
• No potential safe site for aspiration (e.g., Tethered lung,
bullous disease mimicking pneumothorax, small volume
pneumothorax)
• Mechanical ventilation which might increase the chances
of tension pneumothorax or bronchopleural stula (chest
drain preferred)
• Pleural effusions
• No safe site or route identied on USG (very small or
posterior collections given the increased risk of neurovascular structures injury)
A recent radiological study (chest radiograph or USG)
should be reviewed before starting the procedure to verify
the indication and side of the pathology. Ultrasound guidance is recommended prior to pleural uid procedures except
in emergent situations. Screening USG should be done in the
position where the procedure is planned to be done.
Ultrasound guidance is preferred as it increases yield and
reduces complication risks due to its real-time capabilities.
CT guidance may be helpful in some situations, particularly
in cases of loculated pneumothorax/effusion with tethered
37.3.3 Size andType ofNeedle
Small bore needles are preferred to minimize the risks associated with diagnostic pleural aspiration (often needle
21G/40 mm is used). The depth of the uid in the pleural
cavity should be assessed while planning the procedure to
select optimum needle length. It also ensures the needle is
not advanced too far, risking damage to deep structures.
Commercially available kits for therapeutic pleural aspiration generally have larger 6F or 8Fr needles.
37 Nonvascular Thoracic Interventions
461
37.3.4 Technique
A slower and controlled drainage allows gradual reexpansion of the lung. This helps in early identication of
signs and symptoms that might suggest the onset of reexpansion pulmonary oedema like worsening breathlessness, hypoxia or chest tightness allowing the procedure to
be stopped before life-threatening symptoms develop. The
use of a three-way stopcock during aspiration allows drainage to be stopped quickly if required. Monitoring pleural
pressure and elastance with pleural uid manometry does
not prevent pain or procedure-related complications compared to manometry-guided large volume therapeutic
thoracentesis.
Therapeutic aspiration via syringe or gravity is advised.
Vacuum drainage bottles or wall suction should be avoided
in therapeutic thoracentesis as it is associated with high complication rate [7].
37.3.5 Volume ofDrainage
For a diagnostic pleural aspiration, 60ml aspirate is adequate
for evaluation. Due to the risk of re-expansion pulmonary
oedema, 1.5L is recommended as the upper limit in one sitting. However, if the patient develops respiratory distress
before 1.5L is aspirated, the procedure is terminated. Larger
volume drainage/aspiration may be done in certain circumstances with close monitoring.
37.4.3 Drain Size
Surgical drainage generally uses larger bore tubes (up to
32–40 Fr), while image-guided drainage is done using catheters of smaller sizes typically. However, large bore catheters, up to 32F (Thal-Quick, Cook Medical, United States),
are now available. Seldinger drains of up to 14F bore are
suitable for most indications. Serous effusions can be
drained via 8F self-retaining catheters, exudative effusions
require 10–16 F pigtail or Malecot’s catheter (Fig.37.1).
Large-bore drains up to 32F are better suited for conditions,
such as post-surgery, haemothorax and pneumothorax complicated by substantial air leak (as in trauma, secondary
pneumothorax or ventilated patients). Spontaneous or iatrogenic pneumothorax and pleural infected pleural uid collections are managed with chest drains <14 F. However,
larger-bore drains are the preferred rst choice by some
operators for cases with secondary spontaneous pneumothorax who may have large air leaks. In patients with traumatic
pneumothorax, 14F drains are shown to be as effective as
28F drains with no increased complications. Similarly, in
cases of traumatic haemothorax in stable patients, smallbore drains have shown similar outcomes in comparison to
large-bore drains. Chest drains inserted for the purpose of
talc slurry pleurodesis should be at least 12 F as smaller
drains can get blocked with talc particles. In patients with
rib crowding, intercostal space should be measured to determine the tube size to be used [7, 8].
37.4 Intercostal Drainage Catheter
Insertion
37.4.1 Indications
• Refractory pneumothorax
• Large benign or malignant pleural effusion drainage
• Symptomatic pleural effusions in mechanically ventilated
patients
• Pleurodesis
• Infected pleural collection
• Traumatic pneumothorax or haemothorax
• Post-surgical procedures like thoracoscopy, thoracic, or
cardiac surgeries
37.4.2 Contraindications
There are no absolute contraindications for pleural drain
catheter placement, especially in emergencies.
Uncorrected coagulopathy is a relative contraindication.
37.4.4 Site ofCatheter Insertion
The midaxillary line in the fth or sixth intercostal space is
the standard site for catheter insertion directed superior to
inferior. However, the technique needs to be modied in
cases of loculated effusions, depending on the site of loculation. Use of three-way stopcocks is encouraged to prevent air
from being introduced into the pleural space during the procedure. After satisfactory placement of catheter, it should be
connected to an underwater seal drainage bag. USG and uoroscopy can be used for guidance. CT is especially helpful in
the case of rib crowding leading to poor visualization on
USG and in the case of hydropneumothorax (Fig.37.2) [7].
37.4.5 Post-Insertion Care
Chest drains should be immediately clamped if there is
repetitive coughing or the patient complains of chest pain.
Post-procedure report should include details of the sutures
used, distance at which the drain is xed and colour and consistency of uid drained. It should also provide instructions
462
abc
abcd
A. Jayant et al.
Fig. 37.1 USG-guided drainage of pleural uid using trocar technique. (a) USG image showing pleural effusion (star). (b) USG images
showing trocar and catheter being advanced into the pleural effusion
de
(arrows). (c) Final USG image after removal of trocar showing the pigtail catheter in situ within the pleural effusion. (d) Pigtail catheter with
trocar used for the procedure
f
Fig. 37.2 CT-guided drainage of hydropneumothorax. (a and b)
Axial mediastinal and lung window CT images demonstrate right
hydropneumothorax with air fluid level (arrows) and atelectasis of
underlying right lung parenchyma (star). (c) CT image demonstrating puncture needle (arrow) in the right hydropneumothorax.
(d) CT image shows guidewire (arrow) being inserted into the
pleural space through the puncture needle. (e and f) Axial (e) and
coronal (f) maximum intensity projection CT images showing the
pigtail catheter (arrows) inserted into the pleural space over the
guidewire
37 Nonvascular Thoracic Interventions
463
for when to clamp/unclamp the drain, time and modality of
follow-up imaging and whom to contact in case of complications. A follow-up chest radiograph should be done after the
insertion to ensure appropriate drain position. Appropriate
analgesics and 6–8 hourly ushing with 30 ml saline (for
small bore drains) are prescribed as needed.
37.5 Intrapleural Fibrinolytic Therapy
The primary indication for intrapleural brinolytic therapy
(IFT) is empyema that is unlikely to resolve completely with
tube thoracostomy alone due to loculations and brin deposition, resulting in non-expansion of the underlying lung.
Various agents that can be used are streptokinase, urokinase,
recombinant tissue plasminogen activator (rtPA) and DNase.
The use of streptokinase and urokinase has not been shown
to improve outcomes in terms of duration of hospital stay,
surgical referral or death. A combination of rtPA and DNase
has been reported to be more effective than any other combination in terms of morbidity and reduction of surgical referral. A dose of 10mg of tPA and 5 mg of DNase may be
instilled twice daily with a gap of 2hours according to the
MIST2 trial with a dwell time of 2hours should be allowed.
A maximum duration of three days is recommended by the
MIST2 trial [7].
• Whenever possible, it is recommended to use guards over
the plastic dilators for Seldinger drains to prevent inserting an excessive length of the sharp-tipped dilators into
the pleural cavity.
• All chest drains should be secured with sutures to prevent
displacement.
• Chest drains should be immediately clamped if a patient
complains of chest pain or repetitive coughing.
• A follow-up chest radiograph should be done and
reviewed within a few hours of insertion to conrm the
drain position.
• In cases of effusion, the volume of uid that can be safely
drained over specic time periods should be stated in the
post-procedure notes (e.g., 500ml/h).
• If an intercostal drain is not functioning and a new drain
is needed, avoid using the old track when inserting the
new one.
37.7 Indwelling Pleural Catheter Insertion
Indications Generally, an indwelling pleural catheter (IPC)
is considered for patients with malignant pleural effusion
with a life expectancy of more than a few weeks, during
which time the pleural effusion is likely to re-accumulate
(Fig.37.3).
37.5.1 Catheter Removal
The removal should be done by a brisk pull followed by
quickly occluding the wound using a swab. In cases of largebore drains, it is advisable to take help of an assistant in tying
the closing suture. A chest radiograph should be considered
post removal.
In cases of pneumothorax, catheter can be removed without a “clamping trial” if there is full lung re-expansion and
cessation of air leak.
The decision to remove a tube for infected pleural uid
collection is based on several factors, including a reduction
in the size of the pleural uid collection as seen on radiological imaging, clinical resolution of sepsis and fever, and
minimal drainage output (less than 10 ml/day) for
48–72hours.
37.6 Practice Points
• Small-bore drains (less than 14 French) are appropriate in
most cases, including the drainage of empyema.
• Larger bore drains are recommended in cases of unstable
trauma patients, pneumothorax complicating mechanical
ventilation and if pleurodesis is intended.
• First line for recurrent malignant pleural effusion.
• Second line in cases of failed pleurodesis.
• In selected patients with recurrent non-malignant pleural
effusions.
• Routine use of IPC in acute empyema is not recommended. It is useful in cases of empyema where surgical
management has failed or was not possible due to patient’s
comorbidities or poor performance status.
• In general, IPCs are not recommended in the treatment of
simple pleural effusion. Their use may be considered
when more than three aspiration events are required, and
the patient is at high risk for developing complications of
pleural interventions (coagulopathy).
• IPC is not a contraindication to chemotherapy.
37.7.1 Duration
There is no set limit on how long indwelling pleural catheters
(IPCs) can remain in place, as they are intended to be a permanent solution for recurrent pleural effusions. However, the
risk of IPC-related pleural infection increases over time. The
polyester cuff promotes granulation tissue formation and
brosis, which helps anchor the drain in place, reducing the
likelihood of catheter displacement and providing a barrier
to infection.
464
r
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A. Jayant et al.
White "T" Plunger
Flexible Bottle
Foil Seal
Vacuum Bottle
Fig. 37.3 PleurX indwelling pleural catheter system for long-term pleural drainage. (a) PleurX drainage kit with the roller clamp, sheath, access
needle, sheath, syringe and connector tubing. (b) Schematic diagram showing PleurX vacuum drainage bottle and its components
37.7.2 Drainage Frequency andDrainage
Volume
antibiotics combined with surgical debridement. Minimally
invasive endoscopic ultrasound-guided drainage can also be
Cap
Support Clip
Access Tip Cove
Access Tip
Roller ClampDrainage Line
done. It however requires long-term nasogastric intubation
The typical initial drainage frequency is thrice weekly. However,
recent literature indicates that daily drainage increases pleurodesis rates and shortens the time to pleurodesis compared to alternate-day or symptom-guided drainage. Generally, around
500ml of pleural uid is drained, but up to 1500ml may be
removed. In practice, smaller volumes are often drained, as tolerated by patients, and drainage is stopped if the patient experiences chest discomfort or a persistent cough.
with the catheter being gradually withdrawn as the collec-
tion slowly resolves. There is scarcity of literature regarding
percutaneous drainage of mediastinal abscesses because of
limited space within the mediastinum and proximity of
major vascular structures, oesophagus and pulmonary
parenchyma. First evidence of percutaneous drainage of
mediastinal abscess was provided by Gobien etal. in 1984
[9]. Since then, percutaneous CT-guided drainage has been
proven to be associated with high technical and clinical suc-
cess rates [10].
37.7.3 Indications forIPC Removal
• Output of less than 50ml from the IPC on three consecu-
37.8.1 Procedure
tive occasions, no symptoms of uid re-accumulation and
no signicant pleural effusion on imaging.
• Severe pain, non-resolving IPC-related skin/pleural infec-
Drainage can be performed by tandem trocar technique or
Seldinger technique.
tion, signicant device damage and irreversible IPC
blockage with persistent uid formation.
• Pleural tumours like mesothelioma can inltrate along
37.8.2 Trocar Drainage
instrumentation sites, leading to catheter tract metastases,
but do not usually require IPC removal.
A 20G needle is advanced into the collection under image
guidance. The inner stylet is withdrawn and a small amount
of uid is aspirated to ascertain satisfactory needle place-
37.8 Drainage ofMediastinal Collection
ment within collection. With the help of preliminary imaging
and the 20G needle, a self-retaining locking pigtail catheter
Mediastinal abscess, although relatively rare, is a potentially life-threatening condition. Mortality rates can be as
high as 40%. The traditional treatment has been intravenous
attached to a metal stiffener and trocar cannula is advanced
into the collection parallel and approximately 5mm adjacent
to 20G needle. The catheter advanced further into the collec-