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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3869_Библиотеки_им_академика_М_И_Перельмана.pdf
306 G. Behrens and N.H. Patel
• Advanced age.
• Elevated creatinine level: creatinine >2 mg/dL (5.89 times higher bleeding risk)
(Shiham and Siddiqi 2005 ).
• Chronic renal disease (platelet dysfunction).
• Hypertension SBP: >160; DBP: >100; MBP: >120 (3.74 times higher bleeding
risk) (Shiham and Siddiqi 2005 ).
• Post-percutaneous hepatobiliary interventions to prevent bile leaks.
• Post-percutaneous nephroureteral interventions to prevent urinoma.
• Blood patch for co-axial core biopsy of lung lesion.
Contraindications
• No absolute contraindication.
• Fine-needle aspiration without co-axial technique.
Material Selection
Operator Preference
• Gelfoam
◦ 20 cc and 3–6 cc syringes
◦ Three-way valve stopcock
◦ 0.9 normal saline
◦ Scissors
◦ Gelfoam
• Metallic Coils
◦ Bentson guidewire as a coil pusher
◦ Metallic coils
◦ 0.018–0.035 inch depending upon the guiding needle diameter
• N-butyl cyanoacrylate
◦ Not popular US.
◦ More risk of non-target/distal embolization.
◦ N-butyl cyanoacrilates need to be mixed with lipiodol in 1:1 ratio.
• Autologous Blood Clot/Blood Patch
◦ Requires 10 ml of patient’s blood which has been set aside for at least
15 minutes.
◦ Three-way valve stopcock and second 10-cc syringe may be needed.
31 Tract Embolization 307
Procedural Steps
• The co-axial technique with introducer is required in biopsies.
• The drainage catheter needs to be exchanged for a vascular sheath or dila-
tor/catheter.
Gelfoam
• Gelfom slurry/suspension
◦ Cut Gelfoam sponge into square pieces which are 2–4 mm in size and place
pieces into an empty 3- or 6-cc syringe.
◦ In 10-cc syringe, draw up either 10 cc of saline or mixture of 7 cc of saline and
3 cc of contrast, if fluoroscopy is to be used with tract embolization.
◦ Connect both syringes to the three-way valve and mix until complete suspen-
sion of the Gelfoam.
◦ Inject carefully through the introducer needle/cannula slowly.
• Gelfoam pledges
◦ A block of Gelfoam is cut into strips of 2 cm length.
◦ They are tightly rolled by hand into a shape of a cigar/torpedo.
◦ Load into the introducer needle/cannula or sheath.
◦ Then using the sylet or introducer, push the Gelfoam pledget to desired
location.
Metallic Coils
◦ Metallic coil is inserted into the needle/cannula/catheter and positioned at its tip
(Allison 1988).
◦ Holding the pusher wire in place, the needle/cannula/catheter is withdrawn by
5–10 mm, allowing the coil to start forming its shape. Then push the coil out with
the wire to completely deploy.
◦ Repeat the same procedure until the tract is embolized.
N-Butyl Cyanoacrylate
◦ Need to be mixed with lipiodol in a ratio of 1:1 (vial of 0.5 cc mixed with 0.5 cc
of lipiodol (Lyon 2006)).
◦ In cases of biopsies, injected carefully through the guiding needle/cannula.
◦ In cases of drainage catheter, the catheter should be exchanged to a dilator over
the wire.
308 G. Behrens and N.H. Patel
◦ Always withdraw the needle/dilator tip by about 5–10 mm before beginning the
injection of the mixture. Then inject the mixture slowly as you withdraw.
Autologous Clotted Blood/Blood Patch
◦ Need 10-ml of patient’s venous blood which has been set aside for 15-minutes.
◦ Inject through guiding needle/cannula at a rate of approximately 1 ml per
centimeter.
◦ If clotted blood is too thick, connect the syringe to a three-way stopcock. Connect
an empty 10-cc syringe to the other end of the stopcock. Then gently agitate the
clotted blood by slowly pushing it back and forth between the syringes two to
three times. This should break up the clotted blood into smaller pieces that will
then make it easier to inject through the guiding needle/cannula.
Post-procedure Management
• Vital signs.
• Can be performed as outpatient.
• Check for pain at site of intervention.
• US or CT if complication is suspected.
Complications
• Non-target embolization (migration of embolization material) (Riddle and Bilal
2008 and Androussi 2005).
Results
• Technical success: 98–100%.
• Complications are less than 1%.
• Decreases patient’s perception of pain and decreases the amount of required
analgesia (Schmitz-Rode and Blaum 2000).
• Procedural time: 15 min.
Keypoints
• Reduces risk of bile leak, urine leak, hemorrhage, and pneumothorax for
relevant procedures.
31 Tract Embolization 309
• Co-axial biopsy technique or sheath required.
• Gelfoam most popular agent.
• High technical success and low complication rate (Fig. 31.1).
a
c
Fig. 31.1 Coil tract embolization after liver biopsy. (a) US image showing the tip of 17-gauge
guiding needle within the peripheral aspect of the right lobe of the liver. (b) Shows the tip of 18gauge automatic gun for core biopsies within the right lobe of the liver. (c) US image after coil
deployment showing a hyperechoic structure within the biopsy tract. (d) Fluoroscopic image of
the coil
b
d
References
1. Cowan N, Traill Z, et al. Direct percutanoeus transrenal embolization for renal artery injury
following percutaneous nephrostomy. Br J Radiol 1998;71(851):1199–1201.
2. Rosen R, Rothberg M. Transhepatic embolization of hepatic artery pseudoaneurysm following
biliary drainage. Radiology 1982;145:532–533.
3. Nakagawa N, Nakajima Y, et al. Immediate transbiliary embolization of a biliary–hepatic
artery fistula during access for percutaneous biliary drainage. Cardiovasc Intervent Radiol
1994;17(5):295–297
4. Shiham G, Siddiqi, N, et al. Clinical risk factors associated with bleeding after native kidney
biopsy. Nephrology 2005;10(3):305–310.
5. Allison, D. Percutaneous liver biopsy and track embolization with steel coils. Radiology
1988;169:261–263.
6. Lyon S, Terhaar S et al. Percutaneous embolization of transhepatic tracks for biliary
intervention. Cardiovasc Intervent Radiol 2006;29:1011–1014.
7. Riddle C, Bilal A, et al. Migration of gelfoam to the gallbladder after liver biopsy. Pediatr
Radiol 2008;38(7):806–809.
310 G. Behrens and N.H. Patel
8. Androussi, C. Late complication following coil embolization of a biliary leak. ANZ J Surg
2005;75: 614–615.
9. Schmitz-Rode T, Blaum M, et al. Catheter tract embolization after percutaneous transhepatic
biliary intervention. Rofo 2000;172(2):179–183.
10. Bourgouin PM, Shepard JA, et al. Transthoracic needle aspiration biopsy:evaluation of the
blood patch technique. Radiology 1998;166(1Pt1):93–95
Chapter 32
Arterial Embolization Post-percutaneous Biopsy or Drainage
George Behrens and Nilesh H. Patel
Hemorrhage following imaging-guided biopsy and drainage procedures usually
comes from a predictable site, namely the organ undergoing the biopsy or drainage
procedure. Bleeding following “blind” procedures can come from almost anywhere.
Imaging is necessary where there is doubt regarding the source of bleeding, or
whether there is ongoing bleeding following a primary intervention. In this chapter, three common scenarios will be considered (liver, kidney, and lung), but the
general principles are broadly applicable and will not be repeated.
General Considerations
Bleeding Around Drains
This scenario is usually obvious clinically, but even significant bleeding may be
obscured by dressings around the drain site. Bleeding occurs due either to damage
to tissue parenchyma or injury to arteries or veins en route to the drain site or within
an organ. Bleeding will often stop if the tract is tamponaded by increasing the drain
size, similar to the way that bleeding around a vascular sheath can be stopped by
placing a larger sheath.
Drainage Catheter Upsizing
• Indicated in patients with venous bleeding and bleeding around the drain.
• The catheter is removed over-the-wire.
• A vascular sheath is placed and a contrast injection (tractogram) is performed
through the sheath to look for vascular filling.
• A new catheter 1- or 2-French sizes larger than the previous catheter is placed
over-the-wire.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_32,
C
Springer-Verlag London Limited 2010
311
312 G. Behrens and N.H. Patel
• If the catheter has no further drainage but there is concern for further bleeding
from the site, the catheter should be left in situ and capped for a minimum of
4–8 hours.
Bleeding Following Biopsy
This may be occult as the bleeding may be unseen in the chest, abdomen or pelvis.
Clinical suspicion is usually raised due to an increasing pulse rate and falling blood
pressure. Be alert to patients who become agitated or confused, and ensure that the
ward staff knows what to look for and who to call if there is concern.
Post-biopsy hemorrhage may cease spontaneously, but if there is a suggestion of
ongoing bleeding or the patient is hemodynamically compromised, some form of
intervention is indicated.
Risk Factors
Certain patients are at increased risk of complication and this should be noted on
the aftercare instructions. Such risk factors include the following:
• Coagulopathy
• Systemic hypertension
• Related to biopsy/drainage technique
◦ Central biopsies
◦ Diameter of the needle/catheter
◦ Numerous needle passes
• Hypervascular masses
• Cirrhosis
• Advanced age
• Steroid use
• Ascites
• Patients with known cancer have more risk of bleeding than those with diffuse
diseases such as viral hepatitis
Pre-procedure Evaluation
Patient Evaluation
• The first step in the management of post-biopsy/drainage bleeding is to resusci-
tate the patient!
• Note that the patient may become hemodynamically stable during active resus-
citation, if fluid replacement is keeping pace with the rate of bleeding. Such
32 Arterial Embolization Post-percutaneous Biopsy or Drainage 313
resuscitative efforts should be considered supportive, and clinical suspicion
should remain for ongoing bleeding.
Imaging
• The second step in the management of post-biopsy/drainage bleeding is to
localize the area of bleeding.
• Hemodynamically stable patients: CT is typically performed to determine
whether there is active bleeding and to attempt to determine the underlying cause
(See Fig. 32.1).
• Unstable patients require emergency angiography with the intent to treat or
operative intervention.
Fig. 32.1 CT examination in patient with severe hypotension after percutaneous and US-guided
biopsy of the right kidney showing a large pararenal hematoma with displacement of the kidney
Laboratory
• Hemoglobin and hematocrit levels are performed serially to assess the pres-
ence of ongoing bleeding. Be aware that active resuscitation with fluids only
will present with a significant decrease in hemoglobin and hematocrit levels.
Additionally, brisk bleeding without resuscitation will show NO acute change
in the hemoglobin or hematocrit levels and should not dissuade aggressive
intervention.
• Coagulation status: the best single intervention to correct severe active bleeding
post-biopsy or drainage in coagulopathic patients is to correct the coagulopathy!
• Platelet count.
• Kidney function.
• Liver function tests.
Indications for Embolization
• Unstable patients
• Hypotension or patients requiring vasopressors
314 G. Behrens and N.H. Patel
• Enlarging hematoma
• Ongoing bleeding despite correction of coagulopathy or thrombocytopenia
Contraindications to Embolization
Contraindications are all relative and include the following:
• Borderline renal failure or elevated creatinine levels
• Severe contrast allergy (may use carbon dioxide)
• Inability to visualize the target vessel
• Bacteremia/sepsis
• These contraindications should NOT preclude an intervention in a patient who
needs it!
Treatment Plan and Technique
Pseudoaneuryms and Active Bleeding
• Aim is to exclude a pseudoaneurysm or injured vessel from the circulation.
◦ Exclusion methods fall into two broad categories
• Embolization
• Stent placement (reserved for large diameter vessels)
◦ Pseudoaneurysm arising from segmental or intralobar arterial branch that does
not have a collateral supply can be treated with just proximal embolization, since retrograde filling of the abnormality (“backdoor bleeding) is not
possible.
◦ Lesions with numerous collateral vessels need to be treated with proximal and
distal coil deployment in order to exclude it from the circulation (by preventing
backflow from the collateral circulation) (See Fig. 32.3 and Fig. 32.4).
Arteriovenous fistula
• Goal is to exclude the AV shunt or at least decrease the pressure enough to permit
time for self-healing.
◦ Superselective technique is mandatory to
• Improve results
• Decrease ischemic complications
32 Arterial Embolization Post-percutaneous Biopsy or Drainage 315
a
Fig. 32.2 (a) Selective right renal angiogram showing normal appearance of the renal artery. (b)
There is extravasation of the contrast material from an extrarenal branch. All the intrarenal branches
are intact. (c) Nephrogram phase showing persistent extraluminal contrast within the inferior aspect
of the kidney
Fig. 32.3 Selective angiogram of right lumbar artery. There is a large pseudoaneurysm with active
extravasation of the contrast material (arrows)
b
c
a
Fig. 32.4 Digital subtraction images after coil embolization of the right lumbar pseudoaneurysm
using four coils. There is a complete exclusion of the sac from the circulation
b
c
• Ideally, the coils need to be deployed in the small feeding vessels, in order to
reduce risk of collateral flow.
• Particulate agents are not used in AV F embolization due to the risk of emboliza-
tion to the venous side!