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94 C. E. Ray Jr. and A. C. Waltman
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considered necessary,
embolic material of choice.
23,24
and Gelfoam pledgets are the
22
Preemptive embolization of
arterial branches that are transected but not actively
bleeding, as evidenced angiographically by complete occlusion secondary to spasm, is advocated by some authors
because the likelihood of delayed hemorrhage is significant in this setting.
22
Finally, many trauma patients are
hypothermic and therefore coagulopathic, delaying clot
formation and possibly allowing retrograde collaterals to
open and bleed.
25
Posttraumatic hemorrhage also can be visualized in
other organ systems such as the kidney,
24
liver.
Organ preservation is often the goal in such pa-
24
spleen,
17,26
and
tients, and superselective catheterization and embolotherapy in a hemodynamically stable patient are warranted. In unstable patients, however, proximal occlusion
may be the most timely and effective therapy. In the
setting of active bleeding from the spleen following blunt
trauma, proximal coil occlusion of the splenic artery obviated laparotomy in 94% of patients, and splenic salvage
was achieved in 97% of patients.
26
Iatrogenic trauma,
including complications arising during diagnostic
angiography, also may be amenable to transcatheter embolotherapy.
27
Arteriovenous malformations
Vascular malformations represent vascular abnormalities
that can be characterized best by the appearance of the
endothelial cells at histologic examination.
28
AVMs, as
opposed to hemangiomas, demonstrate normal endothelial cells and mast cells that tend to grow over time; histologically, multiple arteriovenous communications, are
present representing the nidus of the malformation, with
multiple feeding arteries and draining veins. Conversely,
arteriovenous fistulae (AVFs) represent a single communication between a feeding artery and a draining vein,
usually occurring in larger vessels than those seen with
AVMs.
AVMs are a clinically difficult entity, often requiring
several surgical procedures that may or may not be curative. AVMs can be divided into primarily arterial malfor-
mations, demonstrating high-flow and arteriovenous
shunting, and primarily venous malformations, demonstrating phleboliths and slow flow.
29
Unless the nidus is
embolized, AVMs will continue to recur and grow over
time; in addition, several niduses may be encountered.
Embolotherapy is directed against the nidus rather than
the feeding arteries because embolization of the feeding
vessels will occlude flow only temporarily and will stimulate collateral flow to the AVM. Because the targeted
vessels are small, embolization agents include small particles or, most frequently, liquid agents such as glue or
alcohol (Fig. 8-2).
17,30-32
In patients with predominantly
venous malformations, or in those with lesions than are
anatomically difficult to treat by transcatheter arterial
embolization, direct puncture and alcohol instillation
on the venous side of the malformation have proved
efficacious.
33
AVFs constitute a distinct histopathological entity with
both a single feeding artery and a single draining vein.
Because of this single, relatively large communication,
and because preservation of the feeding arter y is a primary goal, larger embolic agents such as coils are most
efficacious when placed directly into the fistula it-
17,30,34
self;
if the fistula cannot be entered directly, the
fistula may be sandwiched by placing coils into the feeding artery proximal and distal to the fistula, thus essentially isolating the fistula and preventing flow into it so
that it may thrombose. Although this method may be
effective, it can be used only when the feeding artery can
be sacrificed completely without risk to organs distal to
the fistula.
Pulmonary AVMs have a variety of histologic subtypes,
the most common type involving a single feeding artery
and a single draining vein, therefore representing a fistula rather than a malformation. Whereas embolization
with detachable balloons acheived great success in the
past, they are no longer approved by the v.s. Food and
Drug Administration (FDA), nor are they or commercially available.
35
Glue has been used as an embolic agent
although care must be taken to ensure that deposition
occurs only in the fistula itself because downstream embolization could have severe consequences.
30
Organ ablation
Embolization procedures for organ ablation for benign
etiologies include splenic embolization in the treatment
of hypersplenism
36–38
and renal embolization in endstage kidney disease for the management of hypertension
and nephrotic syndrome.
17,39
Splenic embolization can
be performed either as definitive therapy for hypersplenism
37,38
or as a preoperative procedure.36When
used as definitive therapy, it is recommended that 10% to
20% of the splenic arterial supply be spared to prevent
infection from encapsulated organisms.
17,37,38
Because
proximal occlusion of the main splenic artery may compromise pancreatic supply or collaterals may reconstitute
the splenic artery from the short gastric branches,
36
embolization of the intraparenchymal splenic artery
branches or arterioles is recommended. Embolic agents
have included Gelfoam pledgets,
Silastic spheres.
proach 100%,
41
While initial technical success rates ap-
37
platelet counts may decrease again
37,38
PVA particles,40and
within 6 month, indicating recurrent hypersplenism,
and up to 23% of patients may require further interven-
43
tion.
When used as adjunctive therapy before splenectomy to decrease the amount of blood loss at surgery,
embolization can be performed safely with gelatin
sponge particles, PVA particles, coils, or a combination of
these agents.
36
42
Embolization and Chemoembolization
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95
A B
FIGURE. 8-2 A 20-year-old woman with a pulsatile, painful heel mass. A: Diagnostic angiography with the catheter placed above
the popliteal artery trifurcation demonstrates a hypervascular heel mass with large feeding branches arising from the posterior
tibial artery. Notice the early draining posterior tibial vein (
performed with the catheter in the tibioperoneal trunk following embolization with small polyvinyl particles. Note the decreased
vascularity and the lack of early draining veins postembolization.
Renal ablation procedures may be used in patients with
end-stage renal disease who are on dialysis or who are
arrow
) indicating significant arteriovenous shunting. B: Angiography
rior phrenic, and ureteral branches should be recognized
and spared if possible.
39
postrenal transplantation in order to prevent renovascular hypertension or nephrotic syndrome arising from the
native kidneys.
17,39
The desired end result for “catheter
nephrectomy” is complete organ necrosis and ablation;
the embolic agents of choice are therfore liquid agents,
such as alcohol, with or without concomitant permanent
large-vessel occlusion with coils.
17,39
If accessory renal
arteries are present, they all must be embolized to allow
complete renal infarction. In addition, arteries arising
from the renal artery such as the inferior adrenal, infe-
Neoplastic
sterile embolization
Embolization of tumors may be performed as an adjunct
to other therapies such as systemic chemotherapy or surgery, as definitive therapy for the treatment of certain
benign neoplasms, as palliative therapy for complications
of neoplasms, or in combination with chemotherapy as
chemoembolization. Sterile embolization procedures in-
96 C. E. Ray Jr. and A. C. Waltman
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clude those in which there is no combination of the embolic agent with chemotherapeutic or immunologic medications (Fig. 8-3).
Sterile embolization for complications arising from primary or metastatic neoplasms may prove helpful. Hemorrhage caused by neoplasms may be treated in the same
manner as bleeding from benign sources discussed above
with some modifications. In particular, hemoptysis arising
from lung carcinoma may arise from the pulmonary as
well as the systemic circulation; pulmonary angiography
is therefore necessary in the absence of a bleeding source
on the bronchial angiogram. Regardless of the organ
involved, care must be taken to avoid permanent central
vascular occlusion, such as with coils, because many tumors are likely to rebleed over time, and vascular access
to the tumor must remain uncompromised. Hyper vascular tumors, such as renal cell carcinoma or carcinnoid,
are more likely to respond to embolotherapy because of
the large amount of neovascularity. Occasionally, hepatic
tumors parasitize blood supply from other vessels, which
also may require embolization.
44
Palliative therapy may be provided by tumor embolization. Tumors causing symptoms by their proximity, size,
or hormonal activity may respond to embolotherapy.
Hepatic arterial embolotherapy, using Gelfoam pledgets,
Gelfoam powder, or PVA particles, has proved efficacious
for symptomatic relief in patients with hormone-secreting tumors metastatic to the liver, with clinical or laboratory response rates ranging from 69% to 100%.
45–47
In-
creased survival rates in patients with metastatic carcinoid
undergoing sterile embolization
46
and sterile embolization of other primary or secondary liver neoplasms have
demonstrated increased survival rates.
48
Doppler ultrasound of the liver before and after embolization may be
helpful in determining residual or recurrent disease.
Embolotherapy also has proved efficacious for control of
tumor-induced hypoglycemia in patients who have fibrosarcoma.
50
In some benign settings, embolization may be considered a curative procedure rather than an adjunct.
Uflacker demonstrated cures in two patients by using
arterial embolization as the sole treatment for benign
insulinomas of the pancreas.
51
Embolotherapy also can be used as a preoperative procedure to decrease the amount of blood loss at surgery.
The goal of embolization in these patients is decreased
blood flow rather than infarction and cell death; therefore, for patients scheduled for embolization close to the
time of surger y, larger agents such as colis have been
used to decrease the major blood supply to tumors
because collateral flow is unlikely to develop prior to
taking the patient to the operating room. A potential
disadvantage to large vessel embolization is the possibility of distal embolization into an aortic branch due to
manipulations performed during the operative procedure. Gelfoam pledgets or large PVA particles may also
be used. Although liquid embolic agents may be help-
52
ful,
they are not used commonly because of the in-
49
A B
FIGURE. 8-3 A 22-year-old woman who had undergone removal of the right kidney for childhood Wilm’s tumor who had develop
left-sided Wilm’s as an adult tumor. Preoperative embolization was performed to decrease blood loss at surgery. A: Selective
digital subtraction angiogram of the left kidney demonstrating solitary left renal artery with neovascular changes compatible with
Wilm’s tumor. B: Selective left renal angiogram showing embolization with Gelfoam pledgets and absolute alcohol and
demonstrating complete cessation of flow to the kidney. Note the preserved flow in the superior capsular and inferior adrenal
branches (
arrow
).
Embolization and Chemoembolization 97
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creased risk and time required when using liquid embolic agents.
Chemoembolization
Chemoembolization combines the effects of locoregional
chemotherapy and embolization during the same procedure to obtain a synergistic effect of both therapies. The
liver is the most commonorgan toundergo chemoembolization because of the high prevalence of disease and dual
vascular supply to the organ. Whereas the normal liver
derives its blood supply largely from the portal vein, in the
setting of hepatic malignancy approximately 90% of the
blood supply to the tumor arises from the hepatic artery,
allowing most of the chemoembolic agent to be delivered
to the tumor rather than to normal parenchyma during
hepatic artery chemoembolization (HACE). Perhaps surprisingly, even in the setting of portal venous obstruction,
A
HACE, may be performed without significant risk of hepatic infarction (Fig. 8-4).
54
Chemoembolization of hepatic malignancies is reserved for surgically unresectable lesions. It should be
considered adjunctive or palliative therapy, although scat-
55
tered cases of cure have been reported.
In addition,
HACE is a multistage procedure, with patients undergoing embolization every 8 to 12 weeks for the duration of
their disease or until hepatic insufficiency develops. The
risks of HACE increase greatly with worsening liver dys-
56–59
function,
and the risk and benefits of repeat proce-
dures should be weighed. Alternative therapies such as
53
systemic or locoregional chemotherapy, percutaneous alcohol ablation, or cryosurgery are other options that may
be considered for the same patient population as those
undergoing HACE. Cryosurgery requires an open surgical procedure, and both percutaneous alcohol ablation
FIGURE 8-4. A 33-year-old man with hepatocellular carcinoma and portal vein invasion was referred for chemoembolization. A: Contrast-enhanced computed tomography
scan of the liver demonstrated diffuse neoplastic involvement of the right hepatic lobe with tumor thrombus occluding the right portal vein (
patent (
lobe. Tumor thrombus is also noted in the inferior vena cava
(
the right hepatic artery demonstrating diffuse neovascularity involving the distribution of the markedly enlarged right
hepatic artery. Note the early visualization of the left portal
vein (
mor thrombus is visualized again in the right portal vein
(
artery showing chemoembolization with Gelfoam and
Adriamycin/mitomycin C/cisplatin slurry. There is marked
diminution of neovascularity within the right hepatic lobe
and no evidence for significant arteriovenous shunting, determined by nonvisualization of the left portal vein as demonstrated in (B).
open arrow
arrowhead
arrowhead
open arrow
). B: Selective digital subtraction angiogram of
). C: Selective angiogram of the right hepatic
arrow
) and supplies an enlarged left hepatic
) due to rapid arteriovenous shunting; tu-
). The left portal vein remains
CB
98 C. E. Ray Jr. and A. C. Waltman
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and cryosurgery are limited by the number and size of
hepatic lesions. Systemic and locoregional infusion chemotherapy requires doses of chemotherapy exceeding
those used for HACE with added side effects for the patient. Only HACE combines the ischemic effects of embolization with locoregional delivery of chemotherapy to
the hepatic malignancies.
Chemoembolization may be performed as an adjunct
to surgery.
60
Increased survival rates in patients with recurrent hepatocellular carcinoma were found in those
who underwent HACE after partial hepatectomy (42%
versus 18% at 3-year follow-up).
60
A 3-year survival rate of
77% was found in patients with initially inoperable hepatotomas who underwent HACE and subsequently were
determined to be operative candidates.
61
The technique used for HACE varies widely according
to the institution where the procedure is undertaken. A
coaxial system frequently is used to increase delivery of
the chemoembolic mixture to the area of greatest interest; in patients with diffuse disease, chemoembolization
may be performed in either the proper hepatic artery or
in both the right and left hepatic arteries selectively. Embolizing one lobe per procedure in patients with diffuse
disease may decrease the likelihood of hepatic insufficiency.
Because tissue necrosis and cell death are the anticipated end results of the procedure, distal embolic agents
are used. Gelfoam powder and small PVA particles are the
most commonly used embolic agents,
58–62
because liquid
sclerosing agents may cause biliary sclerosis or necrosis of
normal hepatic parenchyma. Proximal embolic materials,
in particular coils, are to be avoided because repeat
chemoembolization is the rule rather than the exception
and vascular access to the tumor must be maintained.
Lipiodol also is used frequently either in isolation or in
combination with other embolic agents; lipiodol by itself
has an affinity for hepatomas and presumbly will increase
the amount ofchemoembolic agent delivered to the hepatoma compared with normal surrounding tissue.
57–64
The
chemotherapeutic agent may be delivered first, followed
by embolization, or it may be mixed into a slurry with the
embolic agent itself.The latterprotocol is preferred at our
institutions, because delivery of the chemotherapeutic
agent before embolization decreases the amount of the
agent trapped with the tumor as a result of persistent arterial flow flushing the chemotherapeutic agent from the
hepatic artery into the systemic circulation before arterial
occlusion at embolization.
Protocols for the chemotherapy agents used vary widely
from institution to institution. The most commonly used
agents include Adriamycin,
60,62
and 5-fluorouracil.65The chemotherapeutic agent
C,
57,59
cisplatin,
57,61,63
mitomycin
used should vary depending on the type of hepatic malignancy; in other words, different agents given systemically,
are used for hepatoma metastatic colon carcinoma, and
metastatic carcinoid, and similar agents should be considered for locoregional therapy such as chemoembolization. Consultation with medical oncologists proveshelpful
when deciding on the appropriate drug regimen.
Results for patients undergoing HACE depend on the
type of malignancy being treated. The tumors that have
been investigated most extensively include hepatocellular
carcinoma (HCC). metastatic endocrine tumors, and metastatic colorectal carcinoma. Hepatocellular carcinoma
response rates vary with the protocol used, the size and
histologic type of tumor, and the degree of underlying
hepatic insufficiency. Regarding the degree of insufficiency, patients with more severe underlying liver disease
tend to have decreased survival compared with patients
whose hepatocyte function is relatively normal before
HACE is performed.
58,59
The 2-year survival rates of patients with HCC treated by HACE were 49% 29%, and 9%
for patients with Pugh’s class A, B, and C hepatic dysfunction, respectively in one study.
59
Additional factors that
are poor prognostic indicators include tumor type and
extension, portal vein involvement, tumor area, and presence of ascites and icterus;
66
other studies have shown no
prognostic significance to tumor type and portal vein involvement.
56
Most studies demonstrate a 2-year survival
for HCC treated with HACE of between 33% and
57,63,65
38%,
although survival rates of up to 92% at 2-years
have been reported in patients with HCC with a diameter
smaller than 4 cm.
58
A recent European study, however,
demonstrated no significant increase in the survival rates
for patients with HCC undergoing HACE, although this
study has major methodological shortcomings.
63
Chemoembolization of metastatic endocrine tumors
gives perhaps the best results of all liver malignan-
46,52,65,68–70
cies.
In this patient population, it is estimated
that because of diffuse involvement of the liver fewer than
10% of all patients are surgical candidates.
rates vary from 70% 100%
46,68,70
when using symptomatic
68
Response
relief as the endpoint, whereas biologic response, as evidenced by decreased levels of hormonal breakdown products, is seen in 57% to 100% of patients.
65,68,69
Carcinoid
syndrome appears to respond somewhatmore favorablyto
HACE than to other hormonally active metastatic tu-
69
mors.
Benefits from chemoembolization of metastatic colon
carcinoma are less apparent. Response rates, measured
by a decrease in the size of tumors on follow-up imaging
studies or a decrease in the serum carcinoembryonic
antigen levels, range from 33 to 87%.
55,70,71
One study
demonstrated complete disappearance of liver metastases in 17% of patients, although these results have not
been duplicated.
55
Survival rates in patients who undergo
HACE are comparable to those in patients who undergo
systemic chemotherapy.
72
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99
Adjunctive therapy is of paramount importance in the
HACE patient population. Anticipated side effects of
HACE include right upper quadrant pain, fevers, nausea,
and transiently elevated liver enzymes.
57,61,63–65
Pain is frequently severe enough to warrant narcotic therapy and
should be anticipated by both physician and patient. Nausea usually can be controlled by antiemetic medication
such as granisetron or compazine. Liver enzymes almost
invariably will elevate immediately following the procedure as a result of hepatocyte death; however, persistently
elevated enzymes beyond 3 weeks may indicate hepatic
infarction, and repeat HACE may be contraindicated.
57,63
Infection following HACE is relatively uncommon,
with sepsis occuring in fewer than 1% of patients.
73
Because hepatic abscess formation can be a relatively severe
side effect, broad-spectrum antibiotic coverage is given
immediately before and for 24 hours after the procedure.
Fever following the procedure is relatively common and
may indicate drug effect or tumor lysis rather than infection; however, a persistently elevated fever may indicate
abscess formation and cross-sectional imaging of the liver
should be performed. The imaging results must be interpreted carefully because gas may be visualized in the
tumor or parenchyma following embolization as a result
of the injection of air trapped by the embolic particles
themselves. Persistent or increased amounts of gas on
follow-up imaging studies should increase the suspicion
of infection.
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as second-line treatment in patients with ad-
T. J.DiBartholomeo and C. W. BakalOrganAcc ess Techniques
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9
■■■
Organ Access Techniques
General Principles for Localization, Drainage, and Stenting
THOMAS J. DIBARTHOLOMEO AND CURTIS W. BAKAL
Percutaneous techniques for localization, drainage, and
stent placement are now routine, daily procedures in the
interventional radiology suite. Utilization of multiple imaging modalities allows access to almost all organs and
body compartments. The goal of this chapter is to describe the general principles of localizing and accessing a
target organ for draining collections and for stenting
obstructive lesions.
Virtually any organ or body cavity can be accessed from
a percutaneous route. It is essential to avoid traversing
pleura, bowel, and major vascular structures en route to
the target. On occasion, however, the stomach may be
used as a pathway or ultimate drainage site for pancreatic
collections. In addition to direct, percutaneous access,
the liver can be biopsied via the hepatic veins. If necessary, some solid organs, for example, the liver and kidney,
may be traversed during percutaneous biopsies, aspiration for diagnosis, or drainage.
■ Imaging Modalities Used for Localization
All radiographic and imaging modalities may be used for
accurate localization of the target. A careful review of
relevant preprocedure images should be made. This is
necessary to select the optimal imaging modality for the
procedure, plan the route of access, and determine material requirements for the procedure.
On plain films, some landmarks are especially helpful
and will aid the subsequent fluoroscopic access. A collection may be identified by amorphous-appearing gas.Renal
shadows sometimes are seen, especially in the hydronephrotic, enlarged kidney. Renal calculi aid greatly in localiza-
tion of the kidney. Contrast material may be administered
intravenously to opacifythe renalcollecting systemif renal
function allows. Dilatation of the gallbladder frequently
occurs with biliary tract obstruction. The gallbladder
shadow occasionally is seen, assisting in localization during percutaneous cholecystostomy. Patients who are
postcholecystectomy frequently have surgical clips, which
localize the gallbladder bed.
Under real-time fluoroscopic guidance, the needle,
catheter, or guidewire can be visualized directly, which
permits immediate redirection of the catheter or
guidewire when its course deviates from the desired approach. A damaged catheter or wire can be exchanged
immediately.
The benefits of fluoroscopic guidance tend to result in
an expedient procedure. The disadvantages include relatively poor contrast resolution. Often the target cannot
be seen readily, which may necessitate additional localization punctures. Also, vital structures (e.g., blood vessels)
in the anticipated course may not be readily apparent.
Thus, it is often helpful to do a cross-sectional image
[usually computed tomography (CT)] before a fluoroscopically guided procedure.
patient cooperation (i.e., breathhold for limited motion). There is also radiation exposure to the patient and
physician, although this can be minimized by proper
technique.
Ultrasound (US) has increasingly become an extremely useful modality for target localization. In some
practices, it has become a primary guidance modality for
organ localization. US offers real-time imaging, with potentially excellent tissue contrast for both localization
and needle/catheter tract identification. US is often used
1
Real-time imaging requires
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T. J. DiBartholomeo and C. W. Bakal
in combination with fluoroscopy. For example, during
percutaneous nephrostomy, after localizing puncture
with US, aspiration of about 5 mL of urine is performed,
and the needle is injected with an equal amount of contrast to opacify the system for subsequent fluoroscopic
guidance.
1
US optimally requires specialized needles,
guidewires, and catheters that are sufficiently echogenic
for proper visualization. It is usually cost-effective but is
highly operator and patient dependent.
Computed tomography (CT) is an extremely useful
modality because it provides excellent tissue contrast. CT
provides clear visualization of the course of the anticipated needle tract and will demonstrate any intervening
structures that might preclude placement of the desired
drainage catheter.
2,3
The target lesion or anatomic structure is shown clearly on CT. The disadvantages include
lack of real-time monitoring and delays to check the
progress of needle placement by repeated scanning. Patient cooperation is a necessity because variations in
breathing or breath-holding can result in large variability
in needle placement. CT is a more expensive guidance
technology than fluoroscopy or US. With the advent of
fast CT scans, procedures can be done more expeditiously, although not in real time.
Magnetic resonance imaging (MRI) also provides excellent tissue contrast, imaging in any plane required for
diagnosis, and visualization of the needle/catheter tract;
however, specialized instruments that are nonferromagnetic are required. Conventional MRI does not offer realtime imaging and is presently the most expensive guidance modality. Its primary interventional use is in
neuroradiologic procedures. Real-time MRI “fluoroscopy” is in early development.
■ Goal of Access
Percutaneous access to an organ, abscess cavity, or infected or obstructed anatomic pathway can be performed for biopsy, as described elsewhere in this book.
Aspiration of a fluid collection may be performed for
diagnosis (i.e., culture and sensitivity) or for therapeutic
drainage. In less frequent circumstances, a cavity or
pseudocyst can be sclerosed by alcohol or other agents
to facilitate its closure. Urinary and biliary tract obstructions can be relieved by diverting the path of urine or
bile into an external drainage bag (e.g., biliary drainage)
or by crossing the site of obstruction and reestablishing
the normal antegrade anatomic pathway (e.g., biliary
stenting).
Obstructions are typically caused by calculi, tumor, or
inflammation. Calculi are frequently the cause of urinary
tract obstruction and can result in compromised function
of the affected kidney and infection of the stagnant urine.
Therefore, rapid relief of urinary tract obstruction is im-
portant. The therapeutic drainage procedure is termed
percutaneous nephrostomy tube placement. Tumor is also a frequent cause of obstruction in the urinary tract and biliary
tree. Primary urinary bladder or ureteral tumors (usually
transitional cell) as well as primary pelvic malignancies or
metastases are additional causes of urinary tract obstruction that require nephrostomy. Ureteral stent placement
can be performed percutaneously, but cystoscopic retrograde stent placement usually is attempted first because it
is less invasive than the percutaneous procedure. Percutaneous nephrostomy or ureteral stenting frequently is
performed when the tumor causing the obstruction is
inoperable or is radiosensitive. The ureter frequently responds to radiation therapy with stricture formation.
Therefore, a ureteral stent can be placed prophylactically
or when a stricture becomes symptomatic. Other causes of
stricture include postoperative injury, ischemia, or passage of ureteral calculi. Percutaneous nephrostomy also is
indicated for bladder dysfunction, colovesicular or coloureteral fistulae, or bladder leaks of any cause. Urinary
diversion by nephrostomy drainage or stenting across a
ureteral tear may be used to aid healing.
4
The most common cause of biliary obstruction in the
United States is carcinoma of the pancreatic head. Other
causes include primary bile duct tumors, bile duct stones,
and postoperative injury. Biliary obstruction that results
in pruritis or sepsis requires decompression of the biliary
tree. A temporary stent is used before a planned operative procedure is done or if resolution of the bile duct
obstruction is expected. Typically, permanent stent placement is reserved for inoperable carcinomas. Often a diagnostic cholangiogram and stenting can be performed
in one sitting. It is sometimes helpful to perform a Gram
stain to determine immediately whether a cavity is infected if this is not readily clinically apparent. If positive,
the original puncture then may be used immediately for
placement of a drainage catheter.
■ Materials
Needles
Although a large number and type of needles are available for aspiration and biopsy, only a limited number
are used for organ access and catheter placement. The
prototype is the Chiba needle, a type of aspiration biopsy
needle. The Chiba needle is available in multiple gauge
sizes, although the 21- or 22-gauge “skinny” needles are
used most frequently. If inadvertent nontarget or
vascular puncture occurs or if multiple passes are
needed, this small gauge is relatively atraumatic. Chiba
needles range in length from 10 to 20/cm. The needle
tip is beveled at 25 degrees. Originally designed to obtain
cytologic or bacteriologic samples, skinny needles are
used increasingly to access visceral organs for drainage
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and stenting. (Needles with a greater ability to cut typically are used for biopsy; these are available from a wide
variety of manufacturers and are typically “gun”-type
spring-loaded devices.) For organ access, skinny needles
are used for atraumatic access to the target, for example,
the biliary tree or intrarenal collecting system. The initial
skinny needle approach is completed with contrast
opacification of the target for localization and diagnosis.
Vendor-specific skinny needles are also incorporated as
the initial components of “one-stick” systems used for
upsizing the initial puncture site to allow for drainage
or stenting.
Access to the kidney and biliary trees which are deep,
vascular organs, as well as to many more superficial targets, is typically done with the Seldinger technique; that
is, a needle is first placed into the target and exchanged
over a guidewire for the drainage catheter. Intermediate
dilatation of the track is usually needed. Traditionally,
18- or 19-gauge, 15-cm long, hollow-core needles were
used with exchange over a 0.035-inch to 0.038-inch stiff
working wire (Rosen or Amplatz type). Many interventional radiologists now prefer “one-stick” systems that allow relatively atraumatic localization with a 21-gauge needle and 0.18-inch wire, with subsequent exchange for a
triple coaxial dilator that will accommodate a 0.035-inch
or 0.038-inch working wire. (After this wire is placed, the
track can be dilated to accommodate a standard 8Fr to
12Fr catheter) (Fig. 9-1). An additional drainage-type
catheter is the single-stick trocar. This catheter is loaded
coaxially over a sharp tipped, stiffening needle/cannula
and is inserted directly through a small dermatotomy
into the target site. The catheter is advanced (payed off)
into the target, and the sharp-tipped inner trochar is
removed, leaving the drainage catheter in place (Fig.
9-2). These devices offer the advantage of limited manipulation and speed of insertions, but they must be
used only when a simple, clear path to the target site
from the skin is available. The trocar catheter is used
only after a commitment to therapy via an indwelling
drainage catheter already has been made; it is inappropriate to use this device for simple diagnostic aspiration.
Catheters
Standard directional angiographic catheters and
guidewires are used for providing steerability, maneuverability, and pushability while attempting to negotiate
anatomy, for example, through a stricture, or down a
branch duct. Drainage catheters differ from angiographic flush pigtail catheters and are generally largebore (8Fr to 12Fr) to expedite flow of tenacious material. They have distal configurations (i.e., pigtail), which
are larger than the catheter diameter to help secure
Organ Access Techniques
sd
gw
A
FIGURE 9-1. One-stick technique. A: Skinny needle (21
left
gauge). After entering target, the stylet (
allow passage of an 0.018 inch stiff mandrel guidewire into the
target. B: Coaxial dilator set. The 0.018-inch guidewire (gw)
can support passage of a triple coaxial dilator, which is passed
as a unit. The metal stiffener and inner dilator (sd) are removed; the outer dilator (D) is left in place, allowing passage
of a stiff 0.035-inch or 0.038-inch guidewire, used to support
passage of the final catheter or drain (Cook, Inc., Bloomington,
IN, U.S.A.).
) is removed to
103
D
the catheter. Self-locking mechanisms have been designed to minimize dislodgement.
5
A drainage catheter
has multiple large side holes placed along the distal aspect of the catheter, typically on the inside surface of
the pigtail only and not extending up the catheter shaft
(Fig. 9-2). This circumscribed drainage area ensures that
drainage holes are placed only within the target collection, cavity, or organ. Side-hole location exclusively on
the inner surface allows continued function as the target
shrinks down to abut the outer surface of the pigtail.
Furthermore, the circumscribed location of holes within
the pigtail contains drainage to the target and decreases
the likelihood of leakage back along the track. Side
holes in the track would allow leakage of material into
the track or subcutaneous tissues, leading to infection
and wound breakdown. The drainage holes of abscess
drainage catheters are large to permit the egress of
thick, purulent material. The holes of nephrostomy
catheters may be of only moderate size, allowing drain-
B
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