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116
A.K. Singh
Endpoint
Imaging after placement of abcess catheter and removal of contents ideally shows col-
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lapsed collection.
Complete drainage can sometimes be enhanced by irrigation with small quantities of
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0.9% saline solution making sure to keep the injected volume lower than the volume
initially removed from the cavity in order to minimize bacteremia and sepsis.
Large collections may require more than one catheter for complete drainage.
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If a portion of the collection persists with cathether in good position, it may drain with
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time.
However, if most of the collection persists, consider adjunctive thrombolytics such
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as tPA.
a
b
Fig. 5 Transrectal catheter drainage. (a) Transrectal US shows pigtail drainage catheter (arrow-
heads) within the pelvic abscess. (b) Noncontrast axial CT shows a drainage catheter (arrow-
heads) within the pelvic abscess
117
Drainage of Pelvic Fluid Collections
Results
Percutaneous abscess drainage is successful in 80–90% of cases.
The determinants of high success rate with catheter drainage are:
Postoperative
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Not pancreatic
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Not infected with yeast
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1
The determinants of poor success with catheter drainage are:
Bowel communication or other fistula
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Multiple abscesses
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Crohn’s disease
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Pancreatic abscess
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Infected tumor
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Infected clot
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•
Complications: Complications are rare (<5% in most series) and include hemorrhage,
bacteremia, transient worsening of sepsis, organ injury, bowel injury, and superinfection.
Follow Up
Catheter Management
The catheter is left to gravity drainage and ushed with 0.9% saline solution every 8–12 h
to maintain catheter patency.
Antibiotics are continued and adjusted as necessary based on the culture and sensitivity
results of the abscess contents.
The criteria for catheter removal are:
Most important is the clinical status of the patient. Successful drainage is usually asso-
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ciated with an increased sense of well being.
Defervescence.
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Improvement in leukocytosis.
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Drainage <10–20 mL/day
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Absence of catheter malposition, blockage, or kinking; When present these may neces-
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sitate replacing or repositioning the catheter if residual abscess remains.
Imaging features: Demonstration of a well-drained cavity with no undrained compart-
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ments or loculi.
118
A.K. Singh
Suggested Reading
1. Cinat ME, Wilson SE MD, Din AM. Determinants for successful percutaneous image-guided
drainage of intra-abdominal abscess. Arch Surg. 2002;137:845-849.
2. Jaques P, Mauro M, Safrit H, Yankaskas B, Piggott B. CT features of intraabdominal abscesses:
prediction of successful percutaneous drainage. Am J Roentgenol. 1986;146:1041-1045.
3. Bakal CW, Sacks D, Burke DR, Cardella JF, Chopra PS, et al. Quality improvement guidelines
for adult percutaneous abscess and uid drainage. J Vasc Interv Radiol. 2003;14:S223-S225.
4. Butch RJ, Mueller PR, Ferrucci JT, et al. Drainage of pelvic abscesses through the greater
sciatic foramen. Radiology. 1986;158:487-491.
5. Hovsepian DM. Transrectal and transvaginal abscess drainage. J Vasc Interv Radiol. 1997;8:
501-515.
6. Sperling DC, Needleman L, Eschelman DJ, Hovsepian DM, Lev-Toaff AS. Deep pelvic
abscesses: transperineal US-guided drainage. Radiology. 1998;208:111-115.
Key Points
Success rate of image-guided catheter drainage is 80–90%.
›
During transgluteal image-guided drainage, the catheter should be placed close
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to the sacrum to avoid sciatic nerve injury.
Deep pelvic abscesses can also be drained using transvaginal or transrectal
›
approaches.
Percutaneous drainage catheter size is most often 8–14 French.
›
119
D.A. Gervais and T. Sabharwal (eds.),
Interventional Radiology Procedures in Biopsy and Drainage,
DOI: 10.1007/978-1-84800-899-1_15, © Springer-Verlag London Limited 2011
Drainage of Intrathoracic Fluid Collections
Ajay K. Singh
Clinical Features
Pleural uid collections are common medical issues, occurring frequently secondary to
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pneumonia, surgery, infection, and sometimes neoplasm.
Therapeutic options include thoracentesis, antibiotics, surgical chest tube, or IR cathe-
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ter drainage and surgery (video-thoracospopic or open decortications). Placing an
image-guided percutaneous chest catheter is an attractive alternative to surgically
placed chest tubes because of the advantage of precise placement under image guidance
and small caliber of the catheter (5–14 F versus approximately 24 F for chest tubes).
Pleural effuisions resulting primarily from underlying cardiac, liver, or renal conditions
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are most commonly treated medically and rarely require drainage.
Diagnostic Features
Imaging Appearance
The US appearance of pleural effusion can be anechoic, complex nonseptated, complex
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septated, or echogenic (Fig. 1).
Anechoic collection on US can be transudate or exudate.
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Complex or echogenic collections on US are commonly exudates.
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CT ndings of empyema include lenticular shape, split pleura sign, and gas in pleural
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space.
A.K. Singh
Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
120
A.K. Singh
Thoracentesis
US or CT guidance is often used for diagnostic and therapeutic thoracentesis (Fig.
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2).
Single thoracentesis along with antibiotic therapy may be effective in the rst stage of
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empyema formation.
Not effective in denitive management of malignant pleural effusions as majority will
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recur in 1–3 days. Can be used as temporizing measure.
It is not as effective in managing parapneumonic effusion because of the need for the
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high rate of reintervention, especially when the pH of the uid is low.
1
For large volume uid removal, use small (5–8 F) catheters with direct trocar puncture
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and connect to vacuum source (bottles or wall suction).
Percutaneous Catheter Drainage
Typically 5–14 F pigtail drainage catheters are used (Figs.
•
3–7). Smaller caliber cathe-
ters used in pediatric patients and less viscous uid collections.
Catheter placed using Trocar or Seldinger’s technique.
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Procedure performed under local analgesia. Placement of multiple catheters or difcult
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placement may require anxiolytics or sedatives.
Catheter connected to water seal drainage.
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Achieves more than 80% success rate for pleural uid drainages.
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ab
Fig. 1 Ultrasound appearance of right pleural effusion. (a) Ultrasound of the right lower chest
demonstrates anechoic right-sided pleural effusion (curved arrow). Anechoic pleural effusion can
be secondary to transudative or exudative uid. (b) Ultrasound of the right lower chest demon-
strates complex septated pleural effusion (curved arrow). This appearance is typical for exudative
pleural effusion or empyema
121
Drainage of Intrathoracic Fluid Collections
Indication for Chest Catheter Drainage
Pneumothorax
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Empyema
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Malignant pleural effusion
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Traumatic hemopneumothorax
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Postoperative pleural effusions
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ab
Fig. 2 Catheter drainage of free pleural effusion. (a) Intraprocedural noncontrast CT demonstrates
an aspiration needle tip (arrowhead) placed within a right-sided pleural effusion. High density of
the parietal pleura is because of failed pleurodesis in the past. (b) Noncontrast CT after aspiration
demonstrates a right-sided chest catheter (arrowhead) in the pleural space and marked improve-
ment in the right-sided pleural effusion
ab
Fig. 3 Catheter drainage of loculated pleural effusion. (a) Noncontrast CT of the chest demon-
strates a biconvex, lenticular shape loculated pleural uid collection (arrowhead) located anteri-
orly in the right hemithorax. (b) Noncontrast CT of the chest following pigtail catheter (curved
arrow) drainage demonstrates marked improvement in the size of the pleural uid collection
122 A.K. Singh
Failed surgical chest tube drainage
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Mediastinal and lung abscess
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Indicators of Successful Drainage
Anechoic collection.
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Transudative uid.
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Lack of septations or multiple loculations.
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Not echogenic.
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No pleural rind.
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However, presence of echoes or loculations does not preclude successful drainage.
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Clinical Scenarios
Parapneumonic Effusions and Empyema
Image-guided catheter drainage usually has success rate of more than 80% and is superior
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to chest thoracostomy tube drainage because of more precise placement (Figs. 2–3).
The three stages of empyema are
•
2
:
1. Exudative stage: The exudative uid is free owing and can be managed by drainage
with antibiotic therapy.
2. Fibrinopurulent stage: Fluid is more viscous and can be managed with drainage.
3. Organizing stage: Pleural peel formation which requires surgical interventions (open
decortication, or video-assisted thoracoscopic surgery).
Indications for drainage of pleural effusion are based on Light’s criteria for exudative
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effusion, i.e., pH < 7.20, glucose level <60 mg/dL, lactate dehydrogenase level >600
IU/L and presence of bacteria on gram staining.
Fibrinolytics have been shown to help in drainage by breaking down brin products and
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rendering uid less viscous.
One algorithm for nbrinolytics involves 4–6 mg tPA in 25–50 mL 0.9% sterile saline
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placed into cavity with 30 min dwell time after which drainage is resumed. Repeat
twice a day for 3 days and follow-up with chest CT to assess adequacy of response.
Rapid drainage of large pleural effusion should be controlled to prevent reexpansion edema.
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Catheter removed once there is imaging resolution of empyema and catheter output is
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less than 20–30 cc/day.
Pneumothorax
Small bore catheters achieve a high success rate and often used for post-biopsy pneu-
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mothorax in radiology department (Figs. 4 and 5).
Chest drainage catheters are connected to closed underwater seal drainage, which may
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be connected to a suction pump.
123 Drainage of Intrathoracic Fluid Collections
Suction pump not routinely used for pneumothorax but has been advocated for nonre-
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solving pneumothorax and after pleurodesis.
There is no evidence to suggest that clamping of chest drain prior to its removal pre-
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vents recurrence of pneumothorax. Clamping of chest catheter followed by a chest
x-ray can allow detection of small air leaks, but not routinely recommended.
Chest catheter removed with patient performing deep expiration or valsalva maneuver.
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ab
Fig. 4 Pneumothorax treatment using percutaneous image-guided approach. (a) Intraprocedural
noncontrast chest CT shows a right-sided pneumothorax which is being aspirated with an 18 G
needle (curved arrow). (b) Noncontrast chest CT after placement of a percutaneous chest catheter
(arrowhead) demonstrating marked improvement in the right-sided pneumothorax
ab
Fig. 5 Percutaneous image-guided treatment of hydropneumothorax. (a) Noncontrast chest CT dem-
onstrating a moderately large right hydropneumothorax (arrow) with secondary atelectasis in the
right lower lobe. (b) Noncontrast chest CT after placement of the right chest catheter (arrowhead)
demonstrating marked improvement in the appearance of the right-sided hydropneumothorax
124
A.K. Singh
Lung Abscess
When nonresponsive to antibiotics, postural drainage and bronchoscopic drainage,
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image-guided catheter drainage allows high success rate of more than 70% after 10–15
days of drainage.
3
If the abscess abuts the pleura, the catheter can be placed without lung parenchymal
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transgression.
Typically involves the use of 7–14 F catheter for drainage (Fig.
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6).
Catheter removed once there is imaging resolution of empyema and catheter output is
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less than 20–30 cc/day.
Mediastinal Abscess
Although mediastinal infection often require surgical debridgement with drainage,
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subacute or chronic loculated collection can be managed with percutaneous
drainage.
Precise positioning is more important because of the proximity to major vessels.
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Direct and shortest approach required under CT guidance.
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Drainage reported with 8.3 F or larger caliber pigtail catheter (Fig.
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7).
Pleurodesis
Three tumors most often causing malignant pleural effusion are breast cancer, lung
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cancer, and lymphoma.
Imaging-guided catheter drainage and talc sclerotherapy is effective treatment for
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malignant effusions.
ab
Fig. 6 Lung abscess drainage. (a) Noncontrast chest CT scan study demonstrating an 8.5 F pigtail
drainage catheter (arrowhead) located in an abscess. (b) Follow-up chest CT scan study after
aspiration with the catheter (arrowhead) demonstrates replacement of the uid in the abscess
with air
125
Drainage of Intrathoracic Fluid Collections
Complete regression of pleural effusion achieved in 51–80% and partial resolution in
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up to 95%.
3
The presence of ascites does not adversely affect the overall success of the procedure
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and should not preclude therapy in such patients.
Pleural effusions due to malignant tumors recur an average of 4 or 5 days after thora-
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centesis, so tube thoracostomy, followed by chemical pleurodesis with doxycycline,
bleomycin, or talc is useful.
Implantable pleural catheters such as the Pleurx catheter can induce sufcient pleural
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irritation by themselves to achieve pleurodesis.
Normal Anatomy
Each lung enclosed in own pleural space.
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Intercostal vessels vary in location though most commonly closer to bottom of rib
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than top.
Internal mammary arteries paramedian.
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Subclavian vessels between clavicle and rst rib.
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Aberrent/Altered Anatomy
Post-surgical change may alter anatomy and imaging appearance.
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Single pleural space communicating bilaterally (bovine lung) will predispose to bilat-
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eral pneumothorax.
Avoid chest wall collaterals from venous or arterial obstruction.
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ab
Fig. 7 Mediastinal collection drainage. (a) Noncontrast chest CT during the procedure demon-
strates a loculated mediastinal uid collection (curved arrow) which is being approached with an
18G aspiration needle. (b) Follow-up chest CT during the procedure demonstrates placement of a
pigtail drainage catheter (arrowhead) into the uid collection