INTERVENTIONAL RADIOLOG DR M.KILANI,MD,LILLE,FRANCEULTRASOUND & CT
Puncture sitesAccess:•Meticulous guiding ultrasound exam. - Shortest skin-target distance - Avoid blood vessels, biliary tree, bowel - Use Doppler may be helpful - Once access decided: Test respiratory training (deep or shallow) with short apnea to simulatebiopsy momentAdvantages of US: - Real-time visualisation of the target. -Good visualisation of the access window. - Real-time progression of the needle with possible modification of the trajectory.
Interventional Ultrasound Always Avoid AVOID IF POSSIBLE Large vessels, Bowelproximal organ vessels Liver Ureter! Distal vessels Gallbladder Parenchymatousorgans:kidney, spleen, pancreas
CONDITIONS OF REALISATIONOne day HospitalizationAmbulatory (if cooperative, family at home, classical technique)FastingClinical and imaging data - platelets >150 000 - PT >70 %s - TCA < 2x NormalStop anticoagulant TTT 8 days before.Sédation - anxiolytic 2 hrs before No sleeping patient!!
ULTRASOUND Cleaning of probe, keyboard and cable (protocole). Select probe and application depending on procedure (Try to choose sectorial view if linear probe is used)
INTERVENTIONAL PROCEDURE Skin antispetic measures by technician according to protocol Patient covered with sterile field Sterile material on sterile table Cover the US probe with sterile protection
INTERVENTIONAL PROCEDURE Local Anesthesia (10 à 20 cc Lidocaïne 1%) IM or LP needle according to depth of the target - Evaluation of the trajectory - Take care of air in the syringe! - If liver biopsy go to capsule Needle guide (US/TDM) anesthesia Skin deep incision with scalpel axis //ribs (intercostal artery)
GUIDANCE METHODBiopsy Kit : Adaptable systeme on the probe: visualization of target andneedle trajectory“ Free-hand” Technique : Probe is positioned at the entry point with needle along axis ofUS beam allowing visualisation of the whole length of the trajectory(abdominal). Always visualize your entry path with real-time needle progression
GUIDANCE METHOD Always prefer Free-hand technique possibility of orientation adjustment at last minute and angle of skin penetration. Once capsule is traversed no more adjustment possible: withdraw and redress your angle Needle aligned in the axis of US beam to visualize its swhole length If you loose trajectory move probe 1 or 2 degrees/ needle then scree with probe in Doppler mode to search needle
GUIDANCE METHOD Always prefer Free-hand technique Needle aligned in the axis of US beam to visualize its swhole length If you loose trajectory move probe 1 or 2 degrees/ needle then scree with probe in Doppler mode to search needle
Interventional Ultrasound If solid mass : biopsy 18/16 G ‘True cut’ If cystic mass : initial Fine Needle Aspiration (FNA)-Don’t empty-wall biopsy If possible do microbiopsy (histology) of the wall
‘Co-axial’ Technique 2 types : co-axial - tandem Coaxial : 1 large bore needle (19G) in contact with the lesion ;multiple samples taken with smaller and longer needle inserted within it (20G) Advantage : One puncture with multiple samples (<hemorragic risk but only one direction) Tandem : 1 needle in the lesion ; biopsy needle parallel Advantage : trajectory already done and multiple directions of biopsy
Interventional Ultrasound Automatic needle: one action movement Progression with needle tip visualisation during apnea Adjust needle length If gun is used consider length of specimen (wall/necrosis) 3 Specimens Change needle (FNA / microbiopsy) depending on tissue obtained •Biopsy of normal liver also
Liver Increased hemorragic risk if hemangioma puncture Fill the needle track with Gelfoam
Interventional Ultrasound Possible puncture of distal portal or hepatic branches Biopsy subcapsular lesion by penetration through normal liver.Use respiration to move the diaphragm and keep away the pleuram recess from the needle to get below it Coaxial Technique
GUERIDON PRELEVEMENT Sterile table 1 gauze 1 ampoule of normal saline (moisten biopsy) 1 bottle of Formol or wet gauzeIf drainage : tubes of bacteriology for culture & sensitivity
DEALING WITH SPECIMENS BIOPSIES LIVER KIDNEY LYMPH NODES PANCREAS OR ABDOMINAL MASS: 1st time : place on gauze then wet with normal saline (during puncture) 2nd time : Place in formol. FNA OR COLLECTION DRAINAGE : Aspiration with syringe then put aspirate in sterile tube for bacteriological studies.
COMPLICATIONSComplications are rare (0,008% à 0,03 %)-Vasovagal attackSevere complications- hemorrhage, arterio-veinous fistula, hematoma and pneumoperitoneum (liver)- Acute pancreatitis if normal pancreatic tissue- Metastatic seeding of the needle track.