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Thoracic Interventions Jan 2014

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Thoracic Interventions Jan 2014

  1. 1. Thoracic Interventions Andy Vartanian MD; Andrew Forsyth MD
  2. 2. Thoracic Interventions • Thoracentesis • Chest Tube Placement • Transthoracic Needle Biopsy • Pulmonary Vascular Intervention – Thrombolysis/Thrombectomy of Pulmonary Embolism – Treatment of AVM • Bronchial Artery Embolization • Lung Ablation
  3. 3. • Causes: – Malignancy – Heart Failure – Pneumonia – Cirrhosis – Trauma – Chylothorax Pleural Effusion
  4. 4. Pleural Effusion • Indications for drainage: – Symptomatic: Dyspnea, chest pain, cough – Diagnostic studies • Parapneumonic effusion – Occurs in up to 60% of patients with pneumonia1 – 10% require drainage1 1Semin Respir Crit Care Med. 22(2001)591-606
  5. 5. • Imaging – Plain film – CT – US Pleural Effusion
  6. 6. • Technique – Sitting (if patient able) – Use US for skin marking • Yueh catheter • Saf-T-Centesis catheter Thoracentesis • Limit volume for 1st timers and based on symptoms of lung re-expansion
  7. 7. • Complications – Bleeding – Infection – Re-expansion pulmonary edema • Rare • Minimize risk with judicious removal of fluid – Pneumothorax – Solid organ injury Thoracentesis
  8. 8. Chest Tube Placement • Parapneumonic effusion/empyema • Malignant disease • Pneumothorax • Technique – US/CT guidance – Seldinger/Trocar technique – 8-14 French drainage catheters
  9. 9. Results • Chest tube drainage for parapneumonic effusions: up to 78% 2 – Inadequate drainage treated by lytics or larger catheter 2 Eur Radiol. 10 (2000):495-499.
  10. 10. Transthoracic Needle Biopsy • Indications – Suspicion of Malignancy – Suspicion of Infection • Stat biopsy indication extremely rare – SVC syndrome
  11. 11. Transthoracic Needle Biopsy • Contraindications – Absolute • None – Relative • Coagulopathy • Vascular tumors
  12. 12. • Devices Transthoracic Needle Biopsy – Cutting Needles • 17/18 Gauge • 19/20 Gauge – Aspiration Needles • 22-25 Gauge
  13. 13. Transthoracic Needle Biopsy • Complications (address with informed consent) – Bleeding – Infection – Pneumothorax – Hemoptysis – Death – Possibility of non-diagnostic result
  14. 14. • Results Transthoracic Needle Biopsy – Accuracy up to 95% for malignant lesions – Accuracy up to 88% for benign lesions 3AJR 144 (1985 ) ; 281-289
  15. 15. Transthoracic Needle Biopsy (Lung) • Technique • CT guidance • Coaxial needle – 19/20 Gauge set • Patient positioning extremely important • Conscious sedation – Not too heavy! • Documentation of biopsy device within lesion
  16. 16. 86 year old female Optimal patient positioning for biopsy? Dx: Pulmonary adenocarcinoma
  17. 17. 80 year old male Dx: Pulmonary adenocarcinoma
  18. 18. 70 year old male – post biopsy
  19. 19. • Incidence 27%4 • Risk factors Pneumothorax – Transgression of pleural surfaces – COPD – Location of lesion • Up to 15% of pneumothoraces will require chest tube5 4Radiology 229 (2003):475-481. 5Radiology 210 (1999): 59-64.
  20. 20. • Treatment: Pneumothorax – Oxygen (nasal cannula) – Pain control – Evacuation (if needed)
  21. 21. Pneumothorax • Indications for chest tube placement – Pain – Dyspnea – >25% – Getting larger on serial CXRs
  22. 22. • Oxygen • Biopsy side down Hemoptysis • May need bronchial intubation
  23. 23. Pulmonary Embolism • Estimated 530,000 cases of symptomatic PE occur annually in the United States 6 • Approximately 300,000 people die every year from PE 7 • Mortality approaches 58% for patients presenting with PE in hemodynamic shock 8 • 3rd most common cause of death among hospitalized patients 9 6 Blood, 106 (2005): 267a. 7 NEJM, 358 (2008): 1037-1052. 8 Lancet, 353 (1999): 1386-1389 9 Lancet 379 (2012):1835-1846.
  24. 24. • Etiology Pulmonary Embolism – Most PE arise in the veins of the lower extremity – PE can also arise from pelvic, renal, or upper extremity veins • Risk factors – Lower extremity DVT – Immobilization, recent surgery, central venous instrumentation, obesity, smoking
  25. 25. Clinical Presentation • Dyspnea • Chest pain • Symptoms may be sudden in onset or develop over a period of weeks • If there is coexistent pulmonary infarction, patients may present with hemoptysis • Other non-specific symptoms include tachypnea, tachycardia, palpitations, light-headedness, fever, cough, wheezing, rales
  26. 26. Pathophysiology
  27. 27. • Laboratory: Diagnosis – Troponin: May become elevated when there is enough RV strain causing leakage of the enzyme from RV myocytes – BNP: may be elevated with RV dysfunction (CHF, pulmonary HTN, as well as PE) – D-Dimer: Strong negative predictive value
  28. 28. Imaging Pulmonary angiography
  29. 29. Imaging – VQ scan High probability scan Low probability scan
  30. 30. Imaging – CTA (PE protocol)
  31. 31. Diagnostic Imaging • Pulmonary angiography once considered gold standard • CTA is preferred modality • Other imaging modalities include V/Q scan, MRA, Echo
  32. 32. Treatment of PE • Depends on clinical severity, all include: • Resuscitation • Anticoagulation – Should be administered as soon as possible in patients with high suspicion of PE – Does not lyse existing thromboemboli – Prevents further clot formation – Reduces mortality and is considered primary therapy for PE
  33. 33. • IVC filter Treatment of PE – Patients who are not candidates for anticoagulation • Recent surgery, poor compliance, frequent falls, etc. – Patients with large clot burden on anticoagulation thought not to be able to tolerate additional clot – Patients who are going to undergo elective procedure that places them at an increased risk for PE
  34. 34. Treatment of PE • Indications for aggressive management of PE: – Arterial hypotension (<90 mm Hg systolic or decrease of >40 mm Hg) – Cardiogenic shock • Hypoxia • Signs of poor peripheral perfusion – Syncope (cardiovascular collapse and need for CPR) – Signs of right ventricular strain (controversial)
  35. 35. Treatment of PE • Thrombolysis/Thrombectomy – Systemic thrombolysis • IV tPA: 100 mg over 2 hours • Up to 20% risk of bleeding complication • 3-5% risk of hemorrhagic stroke – Surgical thrombectomy 10J Vasc Interv Radiol 20 (2009) 1431-1440.
  36. 36. Catheter directed thrombectomy • Low-profile devices (<10 F) (3 F=1mm) – Catheter-directed fragmentation and aspiration of emboli • Goal of therapies is to reduce clot burden and relieve life-threatening right heart strain
  37. 37. • Helix thrombectomy device • Rotating pigtail Thrombectomy devices
  38. 38. Thrombectomy devices • Aspirex thrombectomy catheter
  39. 39. Catheter-directed thrombolysis • Placement of small catheter within clot to infuse thrombolytic agent directly into clot • Slow, continuous infusion of thrombolytic agent for prolonged period – 1-3 days
  40. 40. Catheter-directed thrombolysis • Tiny catheter slits slowly release thrombolytic
  41. 41. Catheter-directed thrombolysis • Disadvantages – Invasive – Requires ICU monitoring • Advantages – Lower dose of t-PA – Delivered directly into clot
  42. 42. 60 year old male with SOB PA pressure 87/17 mm Hg Mean 43 (Nml PA systolic press 20-30mm HG)
  43. 43. Significant improvement after lysis PA Pressure: 50/10 mm Hg Mean 25 mm Hg
  44. 44. Pulmonary AVM • Congenital connection between a pulmonary artery and vein without an intervening capillary bed • Most commonly associated with hereditary hemorrhagic telangiectasia (HHT) – Up to 80% of patients with AVMs have HHT – Often patients will have multiple AVMs 11Postgrad Med J 78 (2002):191-197.
  45. 45. Pulmonary AVM • Simple AVMs are contained in one pulmonary segment and have a single feeding artery – Accounts for 80-90% of PAVMs • Complex AVMs have feeding arteries from multiple pulmonary segments • Majority are located in the lower lobes
  46. 46. Clinical Manifestations of PAVMs • Right-to-left shunting – Arterial hypoxemia – Paradoxical embolization • Neurologic symptoms reported to occur in up to 60% of patients • Bacterial embolization seen in 19% of patients – High-output heart failure • Rupture of thin walled PAVMs (8%) • Rapid enlargement can occur in pregnancy and lead to hypoxemia and increased risk of bleeding
  47. 47. Indications for treatment • Depends on clinical severity • AVMs with feeding arteries greater than 3 mm should be treated • If multiple bilateral AVMs are present, treat one lung at a time • Critical to avoid air bubbles from entering the catheter
  48. 48. 62 year old female with dyspnea
  49. 49. 15 year old male with new onset seizure
  50. 50. Pulmonary AVM • Thin-walled abnormal vessels that replace normal capillaries between the pulmonary arterial and venous circulation • Congenital – Isolated (~50%) – Associated with Osler-Weber-Rendu Syndrome • Acquired – Trauma – Infection – Hepatogenic angiodysplasia
  51. 51. Pulmonary AVM • Most patients asymptomatic • May present with CVA or brain abscess – Paradoxical embolization • Most common symptoms are dyspnea, fatigue, cyanosis, clubbing, polycythemia • Solitary pulmonary AVMs usually located within the lateral segment of the right middle lobe or within the lingula • Treatment options include surgical resection of the involved lung or embolotherapy
  52. 52. Bronchial artery embolization • Massive hemoptysis defined as expectoration of >300 mL of blood within a 24 hour period • Most common etiologies: bronchiectasis, tuberculosis, bronchogenic carcinoma, aspergilloma • Hemoptysis occurs in up to 90% of patients with aspergilloma • 85-100% success rate with embolization • Surgery remains only true definitive therapy 12Semin Intervent Radiol, 28(2011): 48-62.
  53. 53. 60 year old female with PMHx non-small cell lung CA, aspergillosis, presents with increasing hemoptysis and hypoxia
  54. 54. Right bronchial and intercostal arterial microsphere embolization (Use particles, not coils, for bronchial A. embo)
  55. 55. Thank you for your interest!
  56. 56. 1. Heffner, J., Klein, J. Parapneumonic effusions and empyema. Respiratory and Critical Care Medicine, 22 (2001): 591-606. 2. Shankar, S., Gulati, M., Kang, M., Suri, S. Image guided percutaneous drainage of thoracic empyema: can sonography predict the outcome? European Journal of Radiology 10 (2000):495-499. 3. Khouri, N., Stitik, F., Erozan, Y., Gupta, P., Kim, W., et al. Transthoracic needle aspiration biospy of benign and malignant lung lesions. American Journal of Radiology 144 (1985): 281-288. 4. Geraghty, P., Kee, S., McFarlane, G., Razavi, M., Sze, D., et al. CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle size and pneumothorax rate. Radiology 229 (2003) 475-481. 5. Collings, C., Westcott, J., Banson, N., Lange, R. Pneumothorax and dependent versus nondependent patient position after needle biopsy of the lung. Radiology 210 (1999) 59-64. 6. Heit, J.A., Cohen, A.T., Anderson, F.A. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the U.S. Blood, 106 (2005): 267a. 7. Tapson, V.F. Acute pulmonary embolism. New England Journal of Medicine, 358 (2008): 1037-1052. 8. Goldhaber, S.Z., Visani, L., De Rosa, M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet, 353 (1999): 1386-1389. 9. Goldhaber, S, Bournameaux, H. Pulmonary embolism and deep vein thrombosis. Lancet 379 (2012):1835- 1846. 10. Kuo, W, Gould, M., Louie, J., Rosenberg, J., Sze, D., et al. Catheter directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. Journal of Vascular and Interventional Radiology 20 (2009): 1431-1440. 11. Khurshid, I., Downie, G. Pulmonary arteriovenous malformation. Postgraduate Medical Journal, 78 (2002): 191-197. 12. Sopko, D., Smith, T. Bronchial artery embolization for hemoptysis. Seminars in Interventional Radiology, 28(2011), 48-62. References

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