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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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“When should Ibe reimaged aer treatment of my liver tumor?” are being asked
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directly to the interventional radiologist. ese are some of the important management issues we have included for the reader.
In training scores of residents and fellows, we have shared many tips that we have
found helpful in our ongoing education. An important one is to challenge someone
taking a case to synthesize the case out loud. When we show cases to a group of residents or fellows and ask a question to the person in the proverbial hot seat, invariably there are self-congratulatory nods from several members of the audience before
the person taking the case has nished reviewing the images. When the answer is
revealed, they pat themselves on the back because they “would have said that.” Only
when readers verbalize their ndings and syntheses of cases can they really know
what they “would have said” because they would have said it.
e references were carefully chosen to be clinically relevant, and they are here to
provide additional resources, many generally accepted as white papers or standards
that provide for more in-depth reading.
Finally, but not lastly, we would like to thank Andrea Seils, who proposed this
project to us several years ago and waited patiently, providing all of the guidance
and resources we needed to make it happen. is book never would have happened
without the support and encouragement of Andrea and her fantastic team at Oxford
University Press.
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Contents
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Venous Access:
Cases 1–6 1–18
Biopsy:
Cases 7–20 19–59
Ablation:
Cases 21–26 60–77
Embolization:
Cases 27–45 78–134
Genitourinary Intervention:
Cases 46–51 135–152
Gastrointestinal/Biliary Intervention:
Cas e s 52–61 153–181
Venous Intervention:
Cases 62–75 182–229
Arterial Intervention:
Cases 76–85 230–259
Case 86 260–262
Cases 87–92 263–279
Drainage:
Cases 93–101 280–304
Spine Augmentation:
Case 102 305–307
Case 103 308–312
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History
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▶ Colon Cancer (Needs Vascular Access for Chemotherapy)
Case 1
Figure 1.1
Figure 1.3
Figure 1.2
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Case 1 Mediport
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Figure 1.4 Figure 1.5
Figure 1.6
Findings
▶ Ultrasound shows the internal jugular vein to be patent (arrows) in its typical location lateral to the carotid
artery (Fig. 1.4, star). e needle (hollow arrow) is entering the vein from a lateral approach above the clavicle.
▶ Spot uoroscopic image shows the implantable venous access device (IVAD) over the right chest wall attached
to the catheter entering the internal jugular vein and terminating at the expected location of the cavoatrial
junction (Fig. 1.5, arrow).
▶ Figure 1.6 shows some of the dierent congurations of available devices. From the le is a Bard Power Port,
which supports a ow rate of up to 5 cc/second. In the middle is a standard single-lumen port with tissue
ingrowth holes that can also be used for retention sutures. On the right is a dual-lumen device. Note it is
attached to a single catheter that has a septum separating the two lumens.
Teaching Points
▶ IVADs are good catheters for long-term, intermittent use making them ideal for administration of intravenous
chemotherapy.
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▶ Internal jugular vein is preferred to subclavian vein access for several reasons. With ultrasound-guided
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internal jugular access, there is almost no risk of pneumothorax. Pericatheter thrombus in the internal jugular
vein is most oen asymptomatic whereas in the subclavian vein it can cause signicant morbidity in the
form of upper-extremity swelling. Even asymptomatic catheter-related stenosis in the subclavian vein may
prevent use of the extremity for dialysis gra/stula maturation in the future. Finally, subclavian vein catheters
are subject to the possibility of “pinch-o syndrome” in which repetitive motion of the upper extremity is
complicated by catheter fracture (see Case 4).
▶ Ideal catheter tip location is the cavoatrial junction or high right atrium. Catheters le higher in the superior
vena cava are prone to cause strictures, brin sheath, and thrombus. While the exact location of the cavoatrial
junction is impossible to predict with uoroscopy, it is approximated in children at two vertebral bodies below
the carina, and in adults approximately 4cm below the carina.
Management
▶ IVADs may be le in place as long as they are needed. Most manufacturers recommend that the catheters
should be ushed regularly at 4-week intervals with saline (valved catheters) or heparinized saline.
▶ IVAD placement is a clean procedure, and the use of prophylactic antibiotics has not been shown to prevent
placement-related infection. Procedure-related infections (i.e., within 30days of placement) are seen in
approximately 1%–2% of cases.
▶ Safe access to puncture the silicone septum of the resevoir is achieved with a Huber needle, which is a
noncoring, long-bevel, hollow needle.
Further Reading
Gonda SJ, Li R. Principles of subcutaneous port placement. Tech Vasc Interv Radiol. 2011; 14(4):198–203.
Walser EM. Venous access ports:indications, implantation technique, follow-up, and complications. Cardiovasc Intervent
Radiol. 2012; 35(4):751–764.
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Case 2
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History
▶ Lung Cancer and Superior Vena Cava Occlusion; Requires Access for Chemotherapy. What procedure is being
performed?
Figure 2.1
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Case 2 Translumbar Placement of Implantable Venous Access Device
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Figure 2.2
Figure 2.3 Figure 2.4
Findings
▶ Aneedle is seen overlying the third lumbar vertebra (Fig. 2.2). Contrast injection opacies the inferior vena
cava (IVC; arrows).
▶ Atranslumbar implantable venous access device (IVAD) has been placed (Fig. 2.3) entering the IVC at the L3
vertebral level with the catheter terminating at the expected location of the cavo-atrial junction (arrowhead).
e port resevoir is seen over the lateral lower chest wall (arrow).
▶ In another patient, ultrasound guidance was used for IVC access and to identify (and avoid) the right renal
artery (Fig.2.4).
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Teaching Points
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▶ In patients who need central venous access and have superior vena cava occlusion or occlusion of internal
jugular, external jugular, and subclavian veins, translumbar access may be performed. Alternative access sites
include femoral, hepatic, and renal veins in patients with renal failure.
▶ Access to the IVC may be achieved with uoroscopic guidance or ultrasound guidance in thin patients;
occasionally computed tomography (CT) guidance may be required. To minimize the risk of injury to the
renal vasculature, access should be below the L2-L3 interspace.
▶ Using uoroscopic guidance, the anterolateral vertebral body can be used for reference, and the needle can be
“walked o” the lateral aspect of the vertebra and directed anteriorly and medially to the expected location of
the inferior vena cava. Aspiration of blood from the needle conrms intravascular location, and contrast can
be injected to conrm position within the cava (Fig. 2.1).
Management
▶ Translumbar IVADs can be used in the same manner as devices placed on the chest wall or upper extremity.
e length of the catheter needed is longer, oen 70cm, and the 65cm catheters that are packaged with some
IVADs may be too short.
▶ Catheters should be ushed with sterile saline or heparin every 4 weeks to minimize the risk of catheter
occlusion and formation of biolm within the lumen of the catheter.
▶ e device should be placed over the lower lateral/anterorlateral chest wall to facilitate access. If the port
is placed in the so tissue of the abdomen without the buttress of the rib cage, it may be very dicult to
access.
Further Reading
Denny DF Jr. Venous access salvage techniques. Tech Vasc Interv Radiol. 2011; 14(4):225–232.
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Case 3
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History
▶ A9-Month-Old Boy with Congenital Heart Disease for Peripherally Inserted Central Catheter Placement
Where is the Tip of the Le Sided Catheter?
Figure 3.1
Figure 3.2
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