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37 Nonvascular Thoracic Interventions
465
tion after being released from the trocar cannula/metal stiffener. The nal catheter position is conrmed by imaging. A
50 ml syringe is used to aspirate the abscess cavity until
minimal uid returns. Abscess cavity is then ushed with
5–10 ml of sterile saline followed by additional aspiration
with 50 ml syringe to ensure full decompression of the
abscess cavity. Catheter is then secured in position by suturing to skin.
37.8.3 Seldinger Technique
The collection is punctured with an 18-gauge sheathed needle under image guidance. The position of the tip of needle
is conrmed by removing the inner trocar needle. Small
amount of sample is retrieved and sent for microbiological
analysis. A 0.035-inch guide wire is then advanced into the
uid collection and its position is again conrmed by imaging. Serial dilatation of the percutaneous tract is done using
fascial dilators to the desired catheter size. Finally, a locking pigtail catheter is advanced over the guide wire into the
collection. All purulent material should be aspirated to
completion and ushed with 5–10mL sterile saline solution to ensure complete emptying of the cavity. The catheter is then secured to the skin and placed for gravity
drainage.
37.9.2 Drainage Chest Tube Related
• Pain
• Inappropriate placement
• Symptomatic hypotension
• Iatrogenic haemothorax
• Organ Puncture
• Drain blockage
• Drain displacement
• Surgical emphysema
• Skin infection
• Re-expansion pulmonary oedema
• Pleural space infection
37.9.3 IPC Related
• Pain necessitating IPC removal
• IPC-related infection-supercial (cellulitis) or pleural
infection
• IPC-related pleural effusion
• IPC blockage
• IPC dislodgement
37.10 Drainage ofLung Abscess
37.8.4 Post-Procedure Follow-Up
This includes daily monitoring of output and ushing of
catheter with 10ml of 0.9% saline solution every 8hours to
ensure catheter patency.
37.8.5 Removal
Catheter is removed when daily output decreases to less than
10ml/day for 24–72 hours or when imaging demonstrates
resolution of the abscess.
37.9 Complications
37.9.1 Thoracentesis Related
• Pneumothorax
• Bleeding complications
• Re-expansion pulmonary oedema (RPO) failed procedure/dry tap
• Symptomatic hypotension
• Organ puncture
CT-guided drainage procedure is the management of choice
for patients not responding to medical therapy. Radiological
intervention is generally reserved for large abscesses (>6cm)
and for patients who are unt for surgery. The normal lung
parenchyma traversed should be minimum, and Seldinger
technique is preferred especially when substantial lung
parenchyma is to be traversed. At least 12F catheter should
be inserted.
Relative contraindications: coagulopathy, lack of safe
access route and little evidence of liqueed content on
imaging.
Complications: empyema, pneumothorax and haemothorax.
37.11 Transthoracic Fine Needle Aspiration
Cytology (FNAC)/Biopsy
37.11.1 Pre-Procedure Evaluation
Prior to performing a transthoracic biopsy, all available
imaging of the patient should be reviewed in detail to weigh
the risk/benet ratio of performing the biopsy. It also guides
us in deciding the best modality and potential access routes
to approach the lesion. Bronchoscopic guidance is preferred
466
A. Jayant et al.
for central and endobronchial lesions, USG is preferred for
large peripherally located lesions abutting the pleura and CT
is used for all lesions that are not accessible by bronchoscopy. The sample should be obtained from viable solid
enhancing or PET avid part of the lesion [11].
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 [12].
For such procedures, INR and platelets should be ≤1.5 and
≥50,000 per μL, respectively. Clopidogrel should be withheld 5 days prior to the procedure, and aspirin should be
withheld 3–5days before the procedure. If the patient is on
low molecular weight heparin, one dose should be withheld
if a prophylactic dose is used; two doses to be withheld
before the procedure if a therapeutic dose is used [12]. All
patients planned for transthoracic biopsy should have a short
admission and IV access.
37.11.2 Indications andContraindications
The indications and contraindications for transthoracic sampling are listed in Table37.1 [13, 14].
37.11.3 Technique
Patient positioning—It can be supine, prone or lateral,
depending on the site of the lesion and planned access route.
Prone positioning has the advantage of relatively less movement during respiration and wider intercostal spaces at the
posterior end of the ribs as compared to their anterior ends.
The arms should be raised above the head to widen the intercostal spaces or can be placed in a criss-cross manner on the
chest to retract the scapula for better access to the lesion.
Table 37.1 Indications and contraindications of transthoracic
sampling
Indications
New or enlarging solitary nodule
or mass
Multiple nodules in a patient
without known neoplastic disease
or in prolonged remission
Focal parenchymal inltrates in
which an infectious organism
could not be identied on
bronchoalveolar lavage
Diagnosis of hilar masses
following negative bronchoscopy
Undiagnosed mediastinal mass
Biopsy or re-biopsy of malignancy
for targeted therapy
Contraindications
Absolute
Suspected hydatid cyst/
AV M
Relative contraindications
Severe emphysema or
interstitial lung disease
Uncorrectable bleeding
diathesis
Lack of safe access path to
the lesion
Severe pulmonary artery
hypertension
Positive pressure
ventilation
Patients should be instructed to maintain the position and
breathe quietly in the same rhythm throughout the
procedure.
Access site—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 [11, 14, 15]. A grid of metallic needles is then
placed at the decided access site and a scan is taken in a
limited area. The entry site is then marked with the help of a
grid and axial plane laser light. The skin in this area is sterilized with Povidone Iodine (10%) and alcohol-based antiseptic and anaesthetised using 2% lignocaine. One should be
careful not to puncture the pleura during local anaesthetic
injection.
Needle type and manipulation—Coaxial system is preferred to avoid multiple pleural punctures. 18G/20G coaxial
semiautomatic biopsy guns with dual throw (1 and 2cm) are
commonly used as they provide adequate sample size without increasing the chances of complications. In an 18 G
coaxial biopsy system, the coaxial needle is 17 G and the
biopsy needle is 18G.
The coaxial needle is first advanced into the skin and
subcutaneous tissue incrementally and proper angulation and direction is confirmed before puncturing the
pleura. The pleura should be punctured in one swift
motion and the needle stabilised within the lesion.
After confirming the position of the needle within the
lesion, the inner sharp needle is removed while keeping
the outer hollow needle within the lesion. The biopsy
gun is then advanced through the hollow coaxial needle
and multiple core biopsies are taken (Figs. 37.4 and
37.5). FNAC may be done in cases of highly vascular
lesions or very small lesions and rapid on-site evaluation should be done during the procedure to increase
diagnostic yield (Fig.37.6).
The tissue cores should be placed in a formalin vial for
histopathology and normal saline for microbiological analysis. The needle should be taken out during expiration
while injecting gelfoam or autologous blood batch to seal
the path and reduce the risk of pneumothorax and bleeding
[16–18].
For large lesions that abut the pleural surface and are visualised on USG, a biopsy can be taken under USG guidance
(Fig.37.7).
37.11.4 Post-Procedure Care
Patient is then rapidly rolled to the biopsy side down, and
coughing and talking should be discouraged during the
recovery period. An upright chest radiograph should be
obtained after 1–2 hours to look for any signicant
pneumothorax.
ab
cd
37 Nonvascular Thoracic Interventions
467
a
Fig. 37.4 CT-guided biopsy of right upper lobe mass in a 73-year-old
male patient. (a) Axial contrast-enhanced CT image demonstrates a heterogeneously enhancing mass in right upper lobe (arrow) and enlarged
precarinal lymph node (arrowhead). (b) CT image in prone position
Fig. 37.5 CT-guided biopsy
of an anterior mediastinal
mass. (a) Axial non-contrast
CT image in soft tissue
window shows a large
anterior mediastinal mass
(star). (b and c) Axial
non-contrast CT images
reveal coaxial needle being
advanced (arrows), with the
tip within the subcutaneous
fat in (b) and within the mass
in (c). (d) CT image showing
the tip of the biopsy gun
needle (arrow) in place within
the mass
bc
showing coaxial needle in place within the lung mass (arrow). (c) CT
images showing biopsy gun needle tip (arrow) within the mass through
the coaxial needle
37.11.5 Complications [11, 14, 15]
mothorax and most of them resolve spontaneously.
However, if the pneumothorax is large or increasing in
• Pneumothorax—It is the most common complication,
occurring in around 20% of patients. Most of them are
small with only a few requiring chest tube drainages.
High-ow supplemental oxygen is helpful in small pneu-
size or if the patient is symptomatic, a chest tube should
be placed (Fig.37.8). The incidence of pneumothorax can
be reduced by the following measures:
– Explain to the patient about the procedure.
468
ab
A. Jayant et al.
Fig. 37.6 CT-guided FNAC
of a lesion in lower lobe of
left lung. Axial soft tissue (a)
and lung (b) window images
(prone) showing a small solid
cystic lesion (arrows) in left
lower lobe. CT image (c)
shows the tip of coaxial
needle (arrow) at the margin
of the lesion. CT image. (d)
shows the tip of FNA needle
within the lung lesion (arrow)
advanced through the outer
coaxial needle
a
b
c
d
Fig. 37.7 USG-guided
biopsy of a large intrathoracic
mass using semi-automatic
biopsy gun. (a) USG image
showing coaxial needle in
plane positioned within the
mass (arrow). (b) USG image
showing biopsy gun tip
advanced through the coaxial
needle into the mass (arrow)
– Instruct to not move, talk, cough or breathe deeply dur-
ing or immediately after procedure.
– Use coaxial technique so that the pleura is punctured
only once.
– Avoid interlobar ssures—to avoid traversing the vis-
ceral pleural multiple times.
– Traverse the least amount of aerated lung.
– Avoid bullae or pneumatoceles.
– Use salinoma technique—instillation of saline into the
extrapleural space to displace the lung, pleura or vascular structures.
– Do not take the stylet out from the coaxial needle at
pleural surface.
– Seal the tract with gel foam/autologous blood clot.
– P.E.A.R.L approach: P—Positioning with biopsy side
down, E—needle removal during Expiration, A—
cd
37 Nonvascular Thoracic Interventions
469
Fig. 37.8 Pneumothorax
during CT-guided biopsy. (a)
Axial CT image showing
pneumothorax (star) that
developed while attempting
biopsy of left hilar mass
(arrow) in left lateral
decubitus position. (b–d)
Drainage of pneumothorax.
CT image (b) showing needle
(arrow) being advanced
through the left anterior
axillary approach. (c and d)
showing pigtail drainage
catheter in situ (arrows) with
reduction in left
pneumothorax. Biopsy was
performed after draining the
pneumothorax
a
b
Autologous blood patch sealing, R—Rapid rollover,
L—pleuraL patching.
• Pulmonary haemorrhage (~11%)—It appears as perilesional ground glass opacity on CT with the patient may
develop haemoptysis. Patient should be reassured and put
in biopsy side down position to prevent aspiration of
blood into the contralateral lung. In most of the cases, it is
sought if patient continues to have haemoptysis or if there
is a drop in saturation (Fig.37.9).
• Air embolism (0.01–0.21%)—It results from the needle
traversing the pulmonary vein during inspiration. Hollow
needle should always be occluded with nger, saline
drops or syringe to prevent this.
• Tumour seeding: 0.012–0.061%.
self-limiting. Immediate pulmonology consult should be
470
ab
cd
Fig. 37.9 Pulmonary
haemorrhage during
percutaneous CT-guided left
lower lobe nodule biopsy. (a)
Axial lung window CT image
shows a small nodule with
spiculated margins in left
lower lobe (arrow). (b) CT
image shows the coaxial
needle being advanced
(arrow). (c) Axial CT image
showing the biopsy gun
needle in place within the
nodule (arrow). (d) Postbiopsy CT image showing
pulmonary haemorrhage, seen
ground glass opacities
surrounding the nodule (star
in c and d)
A. Jayant et al.
37.12 Ablation ofLung Tumours
Pre-Procedure Evaluation
37.12.2 Contraindications [11, 19]
Absolute
CT-guided radiofrequency ablation (RFA) is a safe and
effective treatment option for lung cancer patients who
are not surgically t [11]. Generally, patients who are t
• Uncorrected coagulopathy
• Bacteraemia or active infection
to undergo CT-guided percutaneous lung biopsy are good
candidates for RFA. The goal of ablation is to prolong
Relative
disease-free survival and improve quality of life. Most
favourable results are seen in tumours less than 3cm in
diameter.
37.12.1 Indications [11, 19]
• Local therapy for medically inoperable patients with
early-stage primary lung cancer
• Multiple lung cancers when denitive local therapy is
possible
• Pulmonary oligometastasis
• Tumour adjacent to vital organs
• Proximity to vessels larger than 3mm—heat sink effect
37.12.3 Technique
The technique is very similar to that of CT-guided lung
biopsy. For RFA, the electrode is placed into the tumour
using imaging guidance. The electrode is coupled to an
RF generator and is grounded by means of a grounding
pad applied over the thigh. RFA uses electromagnetic
37 Nonvascular Thoracic Interventions
471
energy in the range of 375–500kHz generated by oscillating electric field which leads to tissue heating
(~60–100°C) and cell death [11, 19]. Ablation margins
should ideally extend beyond the tumour margin by 0.5 to
1cm. For tumours larger than 3cm, overlapping probes
can be used.
37.12.4 Post-Procedure Care
• Immediate post-procedure CT should be done to evaluate
the zone of ablation and procedure-related complications
like haemorrhage and pneumothorax.
• Repeat chest radiograph should be done after 1–2hours to
look for any signicant pneumothorax.
• Follow-up can be done with CECT every 3months. Post
RFA, there is development of hypodensity, absence of
enhancement and development of surrounding ground
glass opacity. An enhancing rim of soft tissue surrounding
the zone of ablation is considered reactive if uniform and
less than 5mm. Imaging features suggestive of recurrent/
residual tumour are [20]:
– Change from ground-glass opacity to solid opacity.
– Development of nodules along the electrode tract.
– Overall increase in the size of ablation zone by 1.25
times.
– Enhancement more than that in the pre-ablation scan,
central or nodular enhancement >10 mm, enhancement >15 HU.
– PET-CT—Persistent uptake centrally or at the region
of ablated tumour, increased activity even after
2months, development of nodular activity at the site of
the tumour nodule.
37.12.5 Complications
• Pneumothorax—It is usually self-limiting and doesn’t
require treatment. However, chest tube drainage may be
required if it is large or expanding or causing respiratory
distress.
• Pulmonary haemorrhage—usually self-limiting.
• Pain—usually self-limiting.
• Fever.
• Infection.
37.12.6 Tips andTricks
• The ideal position of RFA probe is along the long axis of
the tumour.
• Normal lung acts as insulation and concentrates RF
energy.
• Lesions close to the visceral pleura are more painful to
ablate than deeper lesions.
• PET is more accurate than contrast CT for follow-up.
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Interventions oftheBiliary Tract
PalakGarg, VishnuPrasadPulappadi,
andS.H.Chandrashekhara
38
Key Messages
1. Pre-intervention imaging (CT/MRCP) is essential to
evaluatethe aetiology and localizethe site of obstruction
for proper planning of the procedure.
2. Adequate pre-and post-procedural antibiotics cover
(Piperacillin+ Tazobactam) is essential to avoid biliary
sepsis.
3. PTBD involves no signicant manipulation of papilla,
hence lower chances of iatrogenic pancreatitis, and is
efcient for proximal tract obstruction.
4. The PTBD target duct should drain at least one-sixth of
the hepatic parenchyma with maintained integrity of the
target lobe parenchyma and its portal vein branch.
5. Check cholangiogram should always be done using
~5–10 ml of low osmolar water-soluble contrast
(Iohexol) to avoid biliary reux and sepsis.
6. Plastic stents used for biliary stenting are retrievable,
require large bore access and therefore are inserted via
an endoscopic route.
7. In cases of benign or operable malignant strictures, plastic stents are preferred due to their retrievable property.
8. Percutaneous biliary stenting is done using selfexpandable metallic stents and the stent is deployed to
cover approximately 2–3cm proximaland 1 cmdistal to
the site of obstruction.
9. The transhepatic cholecystostomy approach is performed using the Seldinger technique and is preferred
due to the lower risk of biliary peritonitis.
38.1 Introduction
A patentbiliary ductsystemis necessary to ensure adequate
biliary drainage. Any mechanical obstruction of the biliary
tract leads to cholestasis, which in clinical terms is known as
obstructive jaundice [1]. The obstruction can be secondary to
either benign or malignant causes.
Clinically, it presents with yellowish discoloration of
eyes, abdominal pain, darkening of urine and pale stools [2].
On laboratory evaluation, there are increased serum bilirubin
(Direct > Indirect), alkaline phosphatase (ALP) and gammaglutamyl- transferase (GGT) levels [3].
For adequate relief of biliary obstruction, radiologists
play an essential role in image-guided percutaneous transhepatic biliary drainage (PTBD), biliary stenting and cholecystostomy. PTBD is a relatively less invasive procedure for the
relief of biliary obstruction [4]. Although the denite treatment for benign obstruction is biliary tract dilatation or stent
placement, PTBD is performed to overcome the acute rise in
bilirubin levels. In advanced cases of malignant biliary
obstruction, that are usually secondary to gall bladder carcinoma and cholangiocarcinoma in Northern India, PTBD and
stenting are palliative treatmentoptions that can help improve
the quality of life and decrease the bilirubin levelto facilitate
chemotherapy.
38.2 Biliary Anatomy
Biliary ducts are extensively evaluated by non-contrast as
well as contrast-enhanced MR cholangiopancreaticography
(MRCP) (non-invasive) and percutaneous cholangiography
P. Garg
Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, Delhi, India
V. P. Pulappadi
Kovai Medical Center and Hospital, Coimbatore, India
S. H. Chandrashekhara (
Department of Radiodiagnosis and Interventional Radiology,
IRCH, 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_38
*)
(invasive). The liver is divided by Couinaud into eight segments, each segment being supplied by its own portal venous
supply and drained by the hepatic venous system [5]. The
biliary ducts run along with the portal venous system [6].
The right posterior duct has a relatively horizontal course
and drains segments VI and VII, whereas the right anterior
duct drains segments V and VIII.They join to form the right
473
474
P. Garg et al.
hepatic duct. Multiple small tributaries drain the segments of
the left lobe of liver and join to form left hepatic duct. The
right and left hepatic duct join at primary conuence to form
the common hepatic duct [7].
The biliary tract can have multiple variations and these
variations make it prone to bile duct injury and leak during
surgery. A common variation involving the insertion of right
posterior segmental duct into left hepatic duct makes it susceptible to injury during hepatic transplantation [7].
The common hepatic duct is joined by the cystic duct to
form the common bile duct (CBD). CBD further continues
its course and drains through the major papilla along with
the pancreatic duct into the second part of the duodenum.
Along its course, CBD is divided into porta hepatis segment, extra- hepatic suprapancreatic segment and intra-pancreatic segment.
38.3 Biliary Obstruction
The various benign and malignant causes of biliary obstruction are listed in Table38.1 [4].
In malignant cases, image-guided procedures such as
PTBD are palliative and help relieve the obstructive symptoms. The various malignant causes for biliary obstruction at
different levels of biliary tract are listed in Table38.2 [8–10].
Malignant obstruction causes obliteration of the lumen of
bile duct along with upstream biliary tract dilation. On imaging, malignant strictures of the biliary tract appear as irregular narrowing or rat tail stenosis. In pancreatic head
malignancy, the classic double duct sign is seendue to dilatation of the biliary as well as pancreatic duct [11]. Hence,
before undergoing any invasive procedure such as ERCP or
PTBD, the patient should undergo a screening cross- sectional
Table 38.1 Various causes of biliary obstruction
Benign obstruction
Malignant obstructionCongenital Acquired
Choledochal cyst Choledocholithiasis
(most common)
Biliary atresia Iatrogenic strictures
(postcholecystectomy)
Strictures secondary
to trauma
Post-inammatory
strictures
Carcinoma of gall
bladder
Cholangiocarcinoma
Pancreatic head
adenocarcinoma
Ampullary carcinoma
Duodenal carcinoma
Extrinsic compression
secondary to
periportal lymph
nodes, stomach and
colon carcinoma
Table 38.2 Malignant causes of biliary obstruction
Level of obstruction Malignant causes
At porta hepatis GB carcinoma, cholangiocarcinoma,
Extrahepatic
suprapancreatic segment
Intra-pancreatic segment Pancreatic head adenocarcinoma,
hepatic metastasis, periportal
lymphadenopathy
Periportal lymphadenopathy, locally
advanced carcinoma stomach, colon
and pancreatic head adenocarcinoma
ampullary carcinoma and duodenal
carcinoma
imaging which can be a contrast-enhanced CT or MRCP.It
helps to delineate the degree of dilation of biliary tract, site
of obstruction and patency of primary and secondary conuences for planning the procedure.
38.4 Percutaneous Transhepatic Biliary Drainage
PTBD refers to percutaneous drainage of bile for relieving
biliary obstruction. It is a relatively safe procedure as it does
not involve manipulation of the papilla, thereby reducing the
risk of iatrogenic acute pancreatitis. However, PTBD done in
non-dilated biliary ducts or in the left lobe requires ultrasound guidance. To improve the success rate of any imageguided procedure, the performing radiologist should ensure
proper catheter selection, patient care and follow-up after
procedure.
38.4.1 Pre-Procedure Evaluation
andPreparation
The primary investigation in a patient presenting with
obstructive jaundice is USG that helps in assessing the extent
of biliary dilatation, patency of primary conuence as well as
delineate the cause and site of obstruction. The patient should
also have a cross-sectional imaging—CECT or MRCP for
planning the drainage.
As PTBD is technically challenging and the biliary tract
is in close proximity to the hepatic artery and portal vein
branches in the portal triad, there is approximately a 2.5%
risk of bleeding during the procedure [12]. As per the Society
of Interventional Radiology (SIR) consensus guidelines,
INR <1.5 and platelet count >50,000/mm3 are advisable to
minimize the risk of bleeding [13]. Anti-platelet drugs such
as aspirin and clopidogrel should be withheld 5days prior to
the procedure, if possible [14]. Also, serum bilirubin levels
are checked to assess the severity of jaundice.