expanse of ultrasonography- guided intervention · imaging guidance-ultrasonography vs ct...
TRANSCRIPT
![Page 1: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/1.jpg)
Expanse of Ultrasonography-
Guided Intervention
Yi-Hong Chou, M.D.
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
National Yang Ming University, School of Medicine, Taipei, Taiwan
![Page 2: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/2.jpg)
Imaging Guidance for
Intervention
Ultrasonography (US)
Computed tomography, or
US and fluoroscopy combined
![Page 3: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/3.jpg)
Intervent-US-89-'01 3
Ultrasonography(US) Guidance
Seldinger, 1953: wire-guided catheterization
Kratochwil, 1969:A-mode-guided puncture
Goldberg & Pollack, 1972:Puncture of abdominal cyst
Holm, 1972:Static B-mode-guided puncture
Late 1970s: Real-time US-guided procedures
(percutaneous, transluminal)
![Page 4: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/4.jpg)
Purposes of
US-guided Intervention
Diagnostic.
Therapeutic.
Pre-surgical Localization.
![Page 5: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/5.jpg)
Patient Preparation
Lab data – PT Prothrombin Time (INR < 1.6)
- PTT Partial Throboplastin Time
- PL Platelet > 50,000
Grugs: Aspirin, NSAID: none x 7 days
Diet: NPO > 6hrs
I.V. access with normal saline in certain cases
Oxygen or conscious sedation if necessary
avoidance of body heat loss in neonate
minimization of radiation doses
![Page 6: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/6.jpg)
US-Guidance / Advantages
Expedient
Real-time
Less expensive
Portable
No ionizing radiation
Safer with CDU
![Page 7: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/7.jpg)
US-Guidance / Disadvantage
Interposition of bowel gas, lung, bone
More difficult in larger patient
Retroperitoneal approach: difficult
Less global view compared with CT.
![Page 8: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/8.jpg)
US-Guided Needling Procdures
• Free hand
• Attached needle guidance
• Electromagnetic
Free Hand
Attachment Device
![Page 9: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/9.jpg)
Advantages / Free Hand
Better specular reflection:
- better visualization of needle
Good for near-field lesion
Good for multiple passes at FNAC
Good for small lesions
![Page 10: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/10.jpg)
Courtesy: Vincent Chan, MD
Longitudinal Direction
Transverse Direction
![Page 11: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/11.jpg)
Intervent-US-89-'01 11
Aspiration Cytology / Biopsy
Aspration cytology21-23 G fine needle, air-dried or fixation.
Liu’s stain; papanicoloau, Giemsa, PAS stain.
Aspiration biopsySurecut, E-Z-EM-Cut, etc.
14-21 G needle
Core or large-bore needle cut biopsy14-20 G needle
Vacuum-assisted biopsy8-12 G needle
![Page 12: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/12.jpg)
Compressed normal tissue
tumor of low activity
Necrotic tissue
Compressed tumor tissue
![Page 13: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/13.jpg)
![Page 14: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/14.jpg)
Value of “Patent Track” Sign on Doppler Sonography AfterPercutaneous Liver Biopsy in Detection of Postbiopsy Bleeding:A Prospective Study in 352 PatientsKyoung Won Kim, Min-Jeong Kim, Hyo-Cheol Kim, Seong Ho Park, So Yeon Kim, Mi-Suk Park, Tae Kyoung Kim
AJR 2007; 189:109–116
-- 5 minutes after the biopsies, this sign was persistently seen in 4 and disappeared in the remaining 39. Patients with a persistent patent track sign more frequently bled than those without it (p < 0.0001). Sensitivity, specificity, positive predictive value, and negative predictive value were 60%, 100%, 75%, and 99%, respectively.
--A patent track sign, immediately after percutaneous liver biopsy, provides excellent screening for postbiopsy bleeding. --This sign strongly predicts postbiopsy bleeding when persistently seen for 5 minutes.
“Patent Track” Sign
![Page 15: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/15.jpg)
Percutaneous
imaging-guided drainage
first-line treatment for infected or symptomatic fluid collections in the abdomen and pelvis, in the absence of indications for immediate surgery
obviate surgery
![Page 16: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/16.jpg)
Catheter insertion procedures
Trocar
Seldinger techniques
![Page 17: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/17.jpg)
Percutaneou GB Drainage
![Page 18: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/18.jpg)
Locations that are Difficultto Access
Pelvis,
subphrenic regions, or epigastric region
Alternative access routes:
- transrectal, transgluteal, transvaginal, intercostal, or transhepatic
Gervais D, Brown D, Connolly SA, Brec SL, Harisinghani
MG, Mueller PR Radiographics. 2004;24 :737-54
![Page 19: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/19.jpg)
Imaging Guidance-
Ultrasonography vs CT
Deep-seated: drainage is performed under CT guidance. CT has certain advantages– better spatial resolution – allowing more accurate depiction of the abscess, adjacent organs,
and organs along the proposed access route
- reduces the likelihood of mistaking fluid-filled bowel loops
for fluid collections
US is a real-time imaging modality– allows the course of needles and catheters to be monitored as they
traverse tissue planes along the path to the abscess
- angulation from the axial plane can frequently be more easily
achieved and monitored with US than with CT
combined with US, fluoroscopy can be useful for performing drainage with the Seldinger technique– avoiding loss of access or guide wire kinking during tract dilatation
![Page 20: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/20.jpg)
Aspiration versus
Catheter Placement Catheter placement is generally favored over
needle aspiration for definitive treatment– the catheter is usually secured in position for several days (2)
Simple aspiration of collections that communicate with bowel is invariably ineffective because immediate reaccumulation of the collection usually occurs once the needle or temporary catheter is removed
Aspiration of abscess inaccessible for percutaneous catheter placement:
– most commonly seen in the pelvis, particularly in patients with Crohn’s disease who have a propensity for developing interloop abscesses
– prior to surgery to make the surgical field clean, facilitating primary bowel anastomosis
– the patient is undergoing immunosuppression therapy
– transgressing intervening bowel with a 20-gauge needle and aspirating the collection dry
![Page 21: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/21.jpg)
Traversal of Organs (I) Collects sometimes cannot be
accessed without traversing an intervening organ:– (a) unsuitable for percutaneous abscess
drainage and the case referred back to the surgeon
– (b) the intervening organ can be traversed with a catheter: stomach and liver are examples of organs that we consider safe to traverse in most circumstances to allow treatment of an epigastric collection when no other option exists
![Page 22: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/22.jpg)
Traversal of Organs (II)
– Ensure that coagulation parameters are normal– The chosen catheter course through the liver be as
short as possible, away from major blood vessels or dilated biliary ducts and away from other organs such as the gallbladder
– The catheter side holes should be completely contained within the abscess to avoid contamination of the adjacent liver or biliary tract
– The stomach is most commonly traversed for percutaneous drainage of pancreatic abscesses or pseudocysts
![Page 23: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/23.jpg)
Transgastric Approach
To promote the formation of a tract between the pancreatic collection and the stomach– A catheter with multiple side holes is deployed with side
holes in both the pancreatic collection and the stomach– usually left in place for 6 weeks to promote the formation
of a cystogastrostomy tract– when a communication exists between a pseudocyst and
the pancreatic duct, the duct contents will theoretically empty into the stomach
– there is no proved benefit to transgastric drainage of pancreatic pseudocysts (the lifetime of such tracts is very short)
![Page 24: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/24.jpg)
Traversing the vagina and rectum
using transcavitary routes for imaging-guided abscess drainage– Most interventional radiologists choose not to
traverse the bladder or small bowel when performing percutaneous abscess drainage
– some authors have attested to the safety of using these routes in extreme circumstances,
i.e., Afferent loop syndrome
![Page 25: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/25.jpg)
Intervening vascular structures
should always be avoided during
percutaneous abscess drainage
Color Doppler US is very useful in avoiding damage to intervening vascular structures
![Page 26: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/26.jpg)
Organs should be avoided being traversed in Drainage Procedure
pancreas, spleen, gallbladder, small and large bowels, urinary bladder, uterus and ovaries, prostate gland, and most blood vessels
![Page 27: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/27.jpg)
Serious incidents of hemorrhage
Injury to the superior and inferior epigastric arteries as well as the internal mammary and intercostal arteries (3)
– placement of catheters through the skin in the midline ensures that the linea alba (an avascular plane) but may be unsafe in patients with portal hypertension
– CDU or review of a preprocedure contrast-enhanced CT scan is advised to demonstrate the course of the superior and inferior epigastric arteries
![Page 28: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/28.jpg)
Abscesses in Difficult Locations-
Deep Pelvis
a transvaginal US-guided approach, a transrectal US- or CT-guided approach, and a transgluteal CT- or US-guided approach– Transvaginal and transrectal US-guided pelvic abscess
drainage is now much easier to perform
CT of the upper abdomen and pelvis before undergoing transrectal or transvaginal US-guided abscess drainage– (a) many pelvic abscesses are associated with collections in the
upper abdomen that may be missed if only transrectal or transabdominal US is performed
– (b) CT allows assessment for organs that may inadvertently be injured by the needle or catheter
– all of our patients receive antibiotics immediately before undergoing transvaginal or transrectal drainage
![Page 29: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/29.jpg)
Transvaginal US-guided drainage of pelvic abscesses
useful for deep-seated abscesses located close to the vagina
no attempt should be made to drain presacral abscesses via the transvaginal route (4)
not traverse UB during the procedure
other intervening structures such as the small bowel or colon
not be used to drain abscesses that are located too high in the pelvis– may increase the risk of bladder or bowel
transgression or vascular injury
![Page 30: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/30.jpg)
Pelvis
in the iliac fossa or pelvic floor extending upward to the lower abdomen
(a) US guidance , and
(b) CT guidance
![Page 31: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/31.jpg)
Acute RLQ Abdomen Pain, F31
US / Appendical abscess
![Page 32: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/32.jpg)
Appendiceal Abscess
3483566020070307
![Page 33: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/33.jpg)
Pelvic/ TOA (I)
![Page 34: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/34.jpg)
Pelvic/ TOA (II)
![Page 35: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/35.jpg)
Gyn-Pelvic/ TOA (IV)
![Page 36: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/36.jpg)
Low Pelvis
low in the presacral space or in the perirectal space or perineum
(a) US guidance , and
(b) CT guidance with
angulation of the gantry
![Page 37: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/37.jpg)
Transrectal US-guided Abscess Aspiration or Drainage
used in female patients with presacral abscesses, and for abscesses that are anterior and posterior to the rectum in male, particularly useful in male patients with prostatic abscesses
using the trocar technique, usually performed with the patient in the left lateral decubitus position
![Page 38: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/38.jpg)
US or CT guidance for transglutealpercutaneous drainage of
a pelvic abscess
transgluteal percutaneous drainage of a pelvic abscess (2)
– if a skin site close to the sacrum is chosen, the sciatic nerve and adjacent vessels can be avoided and large catheters can be placed (6)
![Page 39: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/39.jpg)
Avoid Sciatic Nerve:
Subgluteal Approach
Sciatic
Nerve
LateralMedial
Posterior
![Page 40: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/40.jpg)
Deep Pelvic Abscess
Transgluteal Approach: Sector Transducer Preferred
![Page 41: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/41.jpg)
Interventional US of
Female Pelvis
Devices for interventional Procedure
![Page 42: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/42.jpg)
Drainage of pelvic abscesses in a young woman with fever, pelvic pain.
Drainage
![Page 43: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/43.jpg)
The major drawbacks of
transvaginal pelvic abscess drainage The risk of patient discomfort (4)
– adequate conscious sedation and the administration of lidocaine at the site of vaginal puncture usually help reduce discomfort
Complications: low, no major bleeding complications
Catheter drainage is generally favored over needle aspiration in patients with tubo-ovarian abscesses– trocar method with a hydrophilic catheter (e.g., 7-8-
F) rather than the Seldinger technique (much more time consuming and painful) (more difficult to monitor the position of the guide wire)
![Page 44: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/44.jpg)
Prostatic Abscess - asp.
![Page 45: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/45.jpg)
Prostatic Abscess : Drainage
![Page 46: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/46.jpg)
Subphrenic collections
in many cases parietal pleural transgression cannot be avoided while accessing subphrenic collections
Postsplenectomy subphrenic collections
the splenectomy bed is filled by loops of bowel
the risk of pleural transgression: pneumothorax, pleural effusion, or empyema
Left-sided subphrenic collections: – the operator should be aware that associated pancreatic tail injury,
all fluid aspirated from this area should be analyzed for amylase content, and the catheter should be injected prior to removal to assess for communication with the pancreatic duct
Right-sided subphrenic collections:– US-fluoroscopic guidance has advantages over CT guidance in
gaining access to achieve optimal catheter position
![Page 47: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/47.jpg)
Percutaneous Transhepatic
Cholangial (or Biliary) Drainage
(PTCD, PTBD)
![Page 48: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/48.jpg)
![Page 49: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/49.jpg)
PTBD Puncture Needle
![Page 50: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/50.jpg)
PTBD
![Page 51: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/51.jpg)
Percutaneous Abscess Drainage
![Page 52: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/52.jpg)
Liver Abscess
Cystic lesion with fluid ranging from anechoic
to highly echogenic
Internal septations and stranding
CT: better in diagnosing liquefaction
![Page 53: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/53.jpg)
Lt Subphrenic collections
![Page 54: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/54.jpg)
Lt Subphrenic /Spleen
![Page 55: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/55.jpg)
Epigastrium and Peripancreatic Area
The major consideration: to avoid crossing small or large bowel or major mesenteric, peripancreatic, or retroperitoneal vessels (9)
collections in or near the pancreatic fossa– a safe access route between the stomach and transverse colon
(gastrocolic ligament) – a transhepatic approach, to avoid the gallbladder, and the porta
hepatis
Collections in the region of the pancreatic tail – through the left anterior pararenal space
the pancreatic body and tail:– through the gastrosplenic ligament
transgastric approach for pancreatic and peripancreatic collections: controversy– colon or small bowel should never be transgressed
![Page 56: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/56.jpg)
Intervent-US-89-'01 56
Drainage of Pancreatic
Pseudocyst or Abscess
![Page 57: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/57.jpg)
Retroperitonium
![Page 58: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/58.jpg)
Urinary Tract Obstruction
Can occur at any site
The most common site: ureteropelvic junction (UPJ).
Distal ureteral obstruction
Ectopic ureterocele associated with the duplicated system
Hydro- or Pyonephrosis
![Page 59: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/59.jpg)
Pyonephrosis
Percutaneous Nephrostomy
( PCN )
Renal Carbuncle:Aspiration or Drainage
![Page 60: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/60.jpg)
Difficulties Due to
Thickened Contents
Fibrinous products are often found in abscesses and hematomas
the introduction of adjunctive thrombolytics into the abscess through a catheter has proved effective in many cases
![Page 61: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/61.jpg)
Situations in Which Imaging-guided Drainage Is Inappropriate
only a limited role for catheter placement in certain pancreatitis-related collections
placing a transvaginal drainage catheter for noninfected collections is not appropriate
If clinical evaluation suggests peritonitis, the patient should proceed to surgery even if imaging demonstrates drainable collections– imaging findings may help in deciding between immediate
surgery and percutaneous drainage
a patient with a similar abscess but with extensive and massive free air or fluid remote from the perforationsite should usually undergo surgery for such an “uncontained” perforation.
![Page 62: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/62.jpg)
Situations in Which Imaging-guided Drainage Is Inappropriate
drainage in the presence of free hollow organ perforation and acute peritonitis
diverticular abscesses secondary to perforated diverticulitis: best treated with imaging-guided percutaneous catheter placement– percutaneous treatment combined with administration of
systemic antibiotics permits control of acute “flare-up,”
Symptomatic fluid collections adjacent to surgical implants of any type (eg, vascular grafts, mesh used for hernia repair, joint prostheses) should be drained only if infected– Infection can be confirmed with needle aspiration and Gram stain
and culture.
![Page 63: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/63.jpg)
Conclusion (I)
Knowing the criteria for assessing the appropriateness of imaging-guided drainage for an abscess or collection
Knowing the methods of managing seemingly “undrainable” abscesses
Knowing the the use of alternative access routes (transgluteal, transvaginal, transrectal)
– facilitate the drainage of deep-seated collections that are inaccessible by more traditional routes
![Page 64: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/64.jpg)
Conclusion (II)
Familiar with modifications in patient positioning and in the use of imaging hardware (eg, angling the computed tomography [CT] scanner gantry)
knowing situations in which imaging-guided abscess drainage should not be attempted
the knowledgeable interventional radiologist will often succeed in draining difficult-to-reach abscesses
the informed diagnostic radiologist can help obviate surgery
![Page 65: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/65.jpg)
Intervent-US-89-'01 65
Drainage Major Complications
Hemorrhage
Hollow organ perforation
Fistula
Arteriovenous fistula
Pneumothorax, pyothorax
Sepsis
Death
![Page 66: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/66.jpg)
Emphyseatous Cholecystitis: Drainage
![Page 67: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/67.jpg)
![Page 68: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/68.jpg)
![Page 69: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/69.jpg)
Conclusions
Percutaneous abscess drainage is a safe, effective, and widely used treatment for patients with abdominal or pelvic sepsis
Techniques allowing percutaneous drainage of less accessible intraabdominal abscesses, thus eliminating the need for laparotomy
![Page 70: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/70.jpg)
LEARNING OBJECTIVES
Understand the feasibility of abdominal intervetion or abscess drainage in different anatomic locations.
Identify US and alternative imaging methods that may improve access to deep-seated lesions or collections.
Describe situations in which imaging-guided abscess drainage is either unhelpful or contraindicated.
![Page 71: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/71.jpg)
Intervent-US-89-'01 71
![Page 72: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/72.jpg)
Intervent-US-89-'01 72
![Page 73: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/73.jpg)
Intervent-US-89-'01 73
Percutaneous Tumor
Ablation
![Page 74: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/74.jpg)
![Page 75: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/75.jpg)
Others
![Page 76: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/76.jpg)
Puncture of Balloon for removal of an entrapped Foley Catheter
![Page 77: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/77.jpg)
Problems
![Page 78: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/78.jpg)
![Page 79: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/79.jpg)
![Page 80: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/80.jpg)
Ac. Cholecystitis: Gall Bladder Drainage
![Page 81: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/81.jpg)
PTCD
![Page 82: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/82.jpg)
Radiofrequecy Ablation RFARITA 1500
Sequoia (Acuson,Mountain View,CA,USA), C4-2 Transducer(3MHz)
(expandable electrode needle)
![Page 83: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/83.jpg)
Deployment of Needle Electrode (2 cm) (3 cm) Complete
治療中注意病患狀況與RFA治療機之操 作調整
![Page 84: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/84.jpg)
Item
SizeTemp Power Time Temp Power Time Temp Power Time Temp Power Time
2 cm 80 90 5.5 80 90 5.5 80 90 8.0 80 90 15
3 cm 105 90 5.0* 105 90 7.5 105 90 14.5
4 cm 110 90 7.0 110 90 14*
5 cm 110 110 7.0**
![Page 85: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/85.jpg)
Imaging-Guided Renal Tumor Ablation-
![Page 86: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/86.jpg)
Laparoscopic Renal Cryoablation
![Page 87: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/87.jpg)
Targeting: US+CT
![Page 88: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/88.jpg)
Planning: decide targeting strategy, explain to the patient
![Page 89: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/89.jpg)
Identify the spatial location of an US image
using GPS information from the magnetic field
US-CT/MRI Fusion
![Page 90: Expanse of Ultrasonography- Guided Intervention · Imaging Guidance-Ultrasonography vs CT Deep-seated: drainage is performed under CT guidanceCT has certain advantages –better spatial](https://reader034.vdocuments.mx/reader034/viewer/2022042211/5eb2018a7648e66cd978425c/html5/thumbnails/90.jpg)
2010-
New Vision