This document provides guidance on basic interventional radiology (IR) procedures including venous lines, feeding tubes, and biliary drainage. It describes different types of venous lines including PICCs, ports, and Hickman/Permacath lines. Details are given on indications, contraindications, pre-procedure care, technical steps, post-procedure care, and potential complications. Guidance is also provided on placing feeding tubes including gastrostomy and gastrojejunostomy tubes using push or pull techniques. Technical tips, outcomes, and controversies are discussed for each procedure type.

1. BASIC IR INTERVENTIONS
A layfellow’s guide

2. BASIC IR INTERVENTIONS
Venous lines
Feeding tubes
Biliary drainage
AV graft and fistula declots
IVC filters

3. VENOUS LINES

4. WHAT LINE, WHEN?
PICC Po r t - a - C a t h Hickman
4F or 5F, single or dual-lumen 8F, single lumen 9F, single or dual-lumen
Dwell time: Days to months Dwell time: Months to years Dwell time: Months to years
Chemotherapy, antibiotics, TPN Intermittent access Frequent or continuous access
Chemotherapy, rarely antibiotics Continuous infusions (Pulm
or TPN HTN, dobutamine, etc)
Quinton/Niagara Pe r m a c a t h
13.5F, dual-lumen 14F, dual-lumen
Dwell time: <2 weeks Dwell time: Months to years
Short-term hemodialysis or Hemodialysis or expected repeat
plasmapheresis plasmapheresis
Awaiting AV graft/fistula, or cannot
Rapid infusion
have AV graft/fistula

5. INDICATIONS/CONTRAINDICATIONS
Indications: Contraindications (all are relative):
Short-term venous access Quinton: None
(Quinton, PICC) PICC: None
Long-term venous access Port: Active infection, INR
(Hickman, Permacath, Port) >1.5, platelets <50, neutropenia
Permacath: Sepsis or
bacteremia, INR > 2, platelets <50
Hickman: Sepsis or bacteremia, INR
>2, platelets <50

6. PRE-PROCEDURE
Antibiotics
Required for Port, optional for Permacath and Hickman, unnecessary for
PICC and Quinton
Ancef 1 gram IV
Alternative for PCN allergy:
Clindamycin 600 mg IV or Vancomycin 1 gram IV
Review any prior venograms and cross-sectional imaging

7. PROCEDURE (QUINTON)
1. Right IJ approach favored (subclavian
or femoral if needed)
2. Ultrasound site prior to prepping to
confirm vein patency
3. Prep and administer 10 cc lidocaine in
skin and soft tissues
4. 21 gauge needle with slip-tip
syringe, access vein under
ultrasound, aspirate to confirm
5. Pass microwire into RA and place
micropuncture catheter
6. Upsize to 035 Amplatz wire, direct
into IVC
7. Dilate and place Quinton
8. Flush/aspirate and lock with heparin
(1000 units/cc)

9. PROCEDURE
(PERMACATH/HICKMAN)
1. Initial steps same as Quinton; ensure that IJ
access is as low as possible
2. Before removing micropuncture wire, place at
desired site of catheter tip (cavoatrial junction
to mid-RA) and measure length
3. Once 035 wire in place (in IVC), anesthetize
exit site and tract 3-4 finger breadths below
clavicle
4. Single blade puncture, tunnel catheter to neck
puncture site and pass all the way through up
to hub
5. Serial dilation and place peel-away sheath
(watch with fluoro)
6. Remove inner dilator and pass catheter into
SVC/RA
7. Flush/aspirate and lock with heparin (1000
units/cc for Permacath, 100 units/cc for
Hickman)
8. Suture with 2-0 silk or Prolene

11. PROCEDURE (PORTACATH)
1. Wide prep, antibiotics and full surgical scrub
2. Initial steps same as Quinton; ensure that IJ access is as low as possible
3. Once 035 wire placed, anesthetize port incision site and pocket (about 4 finger breadths
below clavicle)
4. 2 cm transverse incision with 15 blade
5. Open pocket above incision with forceps and finger; should be snug to prevent port flipping
6. Pre-assemble and flush port, attach catheter and tunneler
7. Tunnel catheter through tract and out of neck puncture site and gently pull port into pocket
8. Place catheter over chest and trim to desired length; use micropuncture wire to confirm
9. Serially dilate and place peel-away sheath
10. Pass catheter through peel-away sheath and confirm adequate position with fluoro
11. Peel away sheath and massage catheter smoothly into tract
12. Flush and aspirate port and lock with heparin (100 units/cc)
13. Place 2-3 deep 3-0 Vicryl sutures to approximate incision
14. Place 4-5 subcuticular interrupted 4-0 Vicryl sutures to complete closure
15. Dermabond and place Telfa dressings
16. Consider leaving port accessed (if use within 24-48 hours)

13. TECHNICAL TIPS
MR venography can be very useful in patients with multiple venous occlusions
With IJ access, keep position of carotid in mind, and direct needle away from it
when possible
Low IJ access can be aided by accessing just above clavicle from side of
ultrasound probe
Always place wire down IVC. If difficult, use deep inspiration, or use 5F Kumpe
catheter and/or angled glidewire to cannulate
When right IJ not available, sequential order of veins to be used: Left IJ, right or
left EJ, right or left subclavian, right or left femoral, jugular
collateral, transhepatic, transcaval. Usually venous recanalization should be
attempted prior to resorting to transhepatic or transcaval lines.
Avoid subclavian access on the side of an existing or planned dialysis fistula
Use meticulous sterile technique!

15. POST-PROCEDURE CARE
Keep site clean and dry; no swimming or baths
For showering, site should be covered (e.g. Tegaderm) and kept out of direct
stream of water
Port follow up in clinic in 7 days (call 310-481-7545 for appt)
Sutures for Hickman and Permacath can be removed at 2-3 weeks

16. COMPLICATIONS
Carotid or subclavian artery puncture
With needle: Remove needle, hold firm but non-occlusive pressure for 10-15 minutes
With dilator/catheter: Surgical consult, can consider closure device and/or balloon tamponade
Air embolism
Usually occurs when patient takes a forced inspiration at the time of dilator removal from the
peel-away sheath; a sucking sound is often heard
Air usually passes into outflow tract of right ventricle (may be visible on fluoro); can obstruct pulmonary trunk
Leave patient in supine position until air is absorbed (may take up to 20 minutes)
Continuous vital sign monitoring; administer oxygen by face mask or 100% non -rebreather
If patient not doing well, turn patient on his/her left side and place head down if possible; catheter aspiration
Infection
Exit site or tunnel infection: local erythema, tenderness, induration or drainage; no systemic symptoms; usually
treatable with local wound care and antibiotics; culture exudate if present
Catheter-related bacteremia: fever or sepsis; catheter should be exchanged or removed and IV antibiotics required
Catheter occlusion
Fibrin sheath: forms within a week and may cause catheter dysfunction
Can flush but cannot aspirate; venogram to diagnose
Attempt tPA first; if fails, consider catheter replacement with or without sheath disruption, stripping

17. OUTCOMES
Technical success rate nears 100%
Catheter infection rates are comparable for lines placed in IR suite and OR
5/1000 catheter-days for Quinton
1-2/1000 catheter-days for PICC
1.3/1000 catheter-days for Permacath/Hickman
0-1/1000 catheter-days for Portacath
Asymptomatic catheter-related venous thrombosis occurs in 28-54%
Symptomatic catheter-related venous thrombosis occurs in 2.8-16%

18. CONTROVERSIES
Hickman vs. Groshong Access site
Hickman has simple cut tip; Subclavian vein has higher chance of
Groshong has valved tip pinch-off syndrome and higher
Valved tip prevents need for heparin likelihood of symptomatic occlusion
lock of line Femoral vein has higher infection
But, no improvement in patency risk
Groshong more difficult to place Internal jugular access is favored
whenever possible

19. TROUBLESHOOTING
Catheter occlusion C e n t r a l ve n o u s o c c l u s i o n
1. X-ray to document line position 1. Thrombosis risk: 45% if
2. If position OK, give 2 mg tPA catheter tip in innominate vein;
into line and let dwell 2-3 hours 19% if tip in upper SVC; <5%
if tip in lower SVC or upper
3. If fails, infuse 1 mg tPA/hour
right atrium
over 3-4 hours
2. Treat with anticoagulation
4. Catheter stripping from femoral
vein for ports and Hickmans 3. If fails, remove device and
continue anticoagulation
5. Catheter exchange for
Permacaths and PICCs 4. If this fails, can consider lysis

25. ENTERIC FEEDING TUBES

26. INDICATIONS/CONTRAINDICATIONS
Indications: Contraindications:
Long-term nutritional support Colonic interposition
Long-term SBO decompression Portal HTN
Moderate or large ascites
Previous gastric surgery (relative)
INR >1.5
Platelets <75K

27. PRE-PROCEDURE
NPO 8 hours
Consider 200 cc of dilute barium suspension given the night prior
Consider antibiotics (usually unnecessary)
Consider glucagon 1 mg IV at start of procedure

28. PROCEDURE (PUSH TYPE)
1. Ultrasound and mark liver edge
2. Place small bore NG tube
3. Insufflate stomach
4. Fluoro to confirm safe window – use lateral if
necessary
5. 1% lidocaine, all the way into stomach along
expected path (slightly rightward)
6. 3 T-fasteners; watch under fluoro; inject to
confirm position
7. Puncture stomach and place 035 Amplatz wire
8. Pre-load 8 mm x 4 cm balloon into 18F G
tube
9. Pass balloon/tube over wire, place balloon
into tract and fully inflate
10. Advance balloon and tube into stomach as
balloon deflates
11. Inflate G tube balloon with 10 cc sterile H20
and secure disk

29. PROCEDURE (PULL TYPE)
1. Prophylactic antibiotics (Ancef 1 gram IV)
2. Ultrasound and mark liver edge
3. Place small bore NG tube
4. Insufflate stomach
5. Fluoro to confirm safe window – use lateral if
necessary
6. 1% lidocaine, all the way into stomach along
expected path (toward fundus)
7. Puncture stomach and place 6F sheath
8. Pass wire down esophagus and snare from
stomach using goose-neck snare
9. Secure tube onto wire from oral end and pull
wire and tube through mouth and down
through stomach and abdominal wall
10. Trim tube and place hub; secure outer bumper
against abdominal wall

30. PROCEDURE
(GASTROJEJUNOSTOMY)
1. Usually used for patients with gastric
reflux, aspiration, or poor gastric emptying
2. Initial steps same as push-type gastrostomy
3. Once T-fasteners placed, puncture into
stomach and place 6F sheath
4. Use Kumpe catheter and stiff angled glide
wire to cannulate pylorus and through
duodenum into proximal jejunum
5. Serial dilators with peel-away sheath (22F for
18F GJ tube) or balloon dilation of tract
6. Pass GJ tube over stiff angled glidewire into
jejunum; monitor under fluoro
7. OK to use jejunal port immediately
8. Compared to G tubes, GJ tubes:
Technically more difficult
Clog more frequently
Require more expensive elemental diet
Require slow infusion to prevent
dumping

31. TECHNICAL TIPS
Do not underestimate G tubes!
Review CT scans prior to procedure
Maintain stomach inflation for all steps
Localize colon and stomach using AP and lateral fluoro
Small bowel is only rarely anterior to stomach
In difficult cases, use DynaCT
Antrum or mid-body are best targets (careful of inferior epigastric artery)
Avoid greater and lesser curvatures (gastric/gastroepiploic arteries)
Watch all needle advancements into stomach under fluoro (look for tenting at
needle tip; use logic and avoid needle over-advancement)
If tube does not pass easily, re-inflate balloon, re-inflate stomach, and re-try (don’t
force the tube in, may push stomach away instead)

33. POST-PROCEDURE CARE
Stomach rest for 24 hours (NPO, do not use tube except for decompression)
T-fastener removal in 1 week
Routine flushing of tube before and after each use
Liquefy anything placed through tube (pills should be finely crushed and
liquefied)

34. COMPLICATIONS
Gastrointestinal perforation (especially transverse colon)
If just needle: OK to withdraw, re-direct, and continue procedure (give antibiotics)
If tract dilated or G tube placed: Consult surgery (do not remove tube)
Peritoneal positioning leading to peritonitis
Be critical of final G tube injection to confirm intragastric position
If access to stomach lost during tract dilation, OK to re-puncture and continue; consider
antibiotics and longer stomach rest before feeding
Wound infection
Local skin care; consider Keflex 500 mg PO BID x 7-10 days
Consider tube exchange or removal; Consider CT scan to evaluate for abscess
Aspiration
Consider conversion to GJ tube
Catheter falls out
Have ER place something in tract (Foley catheter)
Can usually re-cannulate established tract within 24 hours of tube dislodgement

35. OUTCOMES
Technical success rate ~98%
Lower morbidity and mortality rate than surgical tube placement
Equivalent morbidity and mortality to endoscopic tube placement
2% major complication rate
6% minor complication rate

36. CONTROVERSIES
Gastropexy? P u l l ve r s u s P u s h ?
Randomized study of 90 patients (48 Pull-type advantages: No
gastropexy, 42 not) gastropexy, no balloon which can
G tube successful in 100% of pexy rupture, mushroom retention device
patients very effective
G tube failed (placed into peritoneal Pull-type disadvantages: Sometimes
cavity) in 10% of non-pexy patients hard to snare wire in
Excoriation or pain seen around pexy stomach, chance of abdominal wall
site in 10% of pexy patients infection, may be harder to convert
Increased number of punctures can to GJ
increase bleeding risk

37. TROUBLESHOOTING
Tu b e o c c l u s i o n Tu b e l e a k a g e
1. Flush with water or saline 1. Secure disc so that balloon is well-
2. Flush with Coca-Cola apposed to inner margin of stomach
3. Pass a wire under fluoro 2. Ensure that balloon is not
obstructing gastric outlet
4. Replace tube
3. Antacids
4. Local antibiotic ointment
5. Paracentesis (if ascites)
6. Upsize tube
7. Use suture to tighten tract

38. BILIARY DRAINAGE

39. INDICATIONS/CONTRAINDICATIONS
Indications: Contraindications (all are relative):
Relieve biliary obstruction when Marked ascites
ERCP has failed or is not indicated Multiple obstructed, isolated biliary
Manage cholangitis segments (sclerosing
Diagnosis cholangitis, mets)
INR >1.5
Platelets <75

40. PRE-PROCEDURE
Antibiotics: Zosyn 3.375 grams IV or Ceftriaxone 1 gram IV
Review cross sectional imaging
Choose desired approach:
Right side: Generally easier to perform under fluoro, less radiation to hands
Left side: Generally easier to perform under ultrasound

41. PROCEDURE
1. Wide prep and insonate liver with
ultrasound
2. Advance 21 or 22 gauge Chiba under US
and/or fluoro
3. Attach contrast syringe with extension
tubing, gentle injection as needle is
withdrawn
4. When duct entered, opacify biliary tree
with contrast and decide if suitable; if
not, repuncture suitable duct
5. Once accessed, pass 018 wire, upsize to
Accustick catheter
6. Use 4F glide catheter and 035 angled glide
wire to navigate through occlusion (if not
infected)
7. Place stiff wire, consider cholangioplasty
(4-8 mm, 2 min inflation, high pressure)
8. Dilate tract and place biliary drain (usually
8-10F)

42. TECHNICAL TIPS
This procedure is painful! Liberal use of narcotics/sedation
Do not use very central bile duct access for tube placement, due to increased
chance of vascular injury
Left access:
1. Use ultrasound liberally
2. Segment 3 is most accessible, but usually posterior to adjacent portal vein
3. Angle rightward with access needle to produce favorable wire trajectory
Right access:
1. Be careful of pleural reflection; access below 10 th rib laterally
2. Advance along course of posterior rib toward hilum, parallel to floor
3. Change angulation if no bile duct accessed (more posterior and cranial)

43. POST-PROCEDURE CARE
Keep site clean and dry; no swimming or baths
For showering, site should be covered (e.g. Tegaderm) and kept out of direct stream of water
Flushing tube is OK but optional; do not aspirate
Benign strictures short course:
1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h
2. Return in 6 weeks, re-inject; if patent, place external drain, cap at 24h
3. If no symptoms develop, remove tube 1-2 weeks later
Benign strictures long course:
1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h
2. At 6 weeks, repeat cholangioplasty, upsize to 12F, cap at 24h
3. At 12 weeks, repeat cholangioplasty, upsize to 14F, cap at 24h
4. At 18 weeks, re-assess, if patent, place external drain, cap at 24h
5. If no symptoms develop, remove tube 1-2 weeks later

44. AV GRAFT AND FISTULA DECLOTS

45. INDICATIONS/CONTRAINDICATIONS
Indications: Contraindications:
Elevated venous pressures Infected vascular access
Decreased flow (<600 mL/min) Long-segment (>7 cm)
Prolonged bleeding after needle stenosis/occlusion – consider
removal surgery
Arm swelling Severe hyperkalemia – place Quinton
instead
Thrombosis
Nonmaturing fistula (by 3 months)
Relative: INR >2.0, platelets <25K

46. PRE-PROCEDURE
Check history; if >2 interventions in last month, surgery may be indicated
Check labs (especially potassium)
Palpate fistula and outline anatomy; ensure absence of infection
Palpate and document pulses, capillary refill, warmth in affected limb
Ultrasound can help delineate anatomy as well as sites of stenosis and best site
for access

47. PROCEDURE (FISTULAGRAM)
1. Access fistula near anastomosis
but pointing toward venous
outflow
2. Place micropuncture catheter
3. If flow is present and no
clot, perform outflow and
central venography followed by
blow-back angiogram of the
anastomosis
4. Consider oblique views to help
define anatomy
5. Interventions as needed

48. PROCEDURE (CLOTTED AV
GRAFT)
1. Access graft near arterial anastomosis, toward venous
outflow; place 6F short sheath
2. 5F Kumpe catheter and glidewire to access axillary vein
3. Central venography
4. Pull-back puffs of contrast until reach area of thrombosis
5. Lace back to sheath with 2 mg of tPA in 10 cc (use most
but not all); give 3000-5000 units heparin IV
6. Access graft near venous anastomosis, toward artery; place
6F short sheath; administer remainder of tPA
7. 6 or 7 mm x 4 cm PTA of all venous limb and graft back to
the sheath; 90 second inflations for areas of stenosis
8. Pass 4 or 5 mm x 2 cm PTA (or Fogarty balloon) across
arterial anastomosis; inflate to 1-2 atm, gently pull across
anastomosis and watch for waist; repeat and angioplasty
waist if present
9. Kumpe catheter across arterial anastomosis and perform
graftogram
10. Repeat venous and arterial PTA as needed, +/- mechanical
11. X-stitch to close puncture sites (3-0 Vicryl)

49. TECHNICAL TIPS
Access sheaths should not cross (reduces flow)
May need Conquest balloon or cutting balloon for resistant venous stenoses
Don’t inject clotted graft; always puff contrast to ensure forward flow prior to
runs
Careful with blow-back angiography, make sure there is no clot; generally better to
cross arterial anastomosis and do a real angiogram
Consider Trerotola device and/or Angiojet if tPA and PTA inadequate
If you’ve done everything and still no good thrill, problem is probably the arterial
anastomosis; critique your angiogram and re-dilate
Central veins are rarely the cause of AV graft/fistula thrombosis, but consider
PTA or stent if rest of circuit is patent
Dilating venous stenoses can be very painful; consider lido injection at site of
stenosis
Keep working until you get a uniform thrill without pulsatility

51. POST-PROCEDURE CARE
OK to use graft or fistula immediately
Purse-string suture can be removed at next dialysis

52. COMPLICATIONS
Venous rupture
Especially upper cephalic vein “cephalic arch” in AV fistulas
Start with manual compression or balloon tamponade (2 5-minute cycles)
If fails, consider stent or stent-graft
Persistent bleeding from entry sites
Usually due to suboptimal X-stitch; does not work if graft/fistula not scarred (<2 months old)
May be due to outflow stenosis; consider fistulogram to re-assess
PE
Theoretical risk from central embolization of clot, but clinically significant PE is quite rare
Arterial thrombosis
If arterial embolus seen on angiogram, but is not symptomatic and is only partially flow limiting,
OK to leave alone (will lyse spontaneously)
If symptomatic (cold, painful, pale hand): heparinize
Immediate angiography and thrombolysis initiation
Occasionally surgical thrombectomy is required, if dislodged clot is old and not lyseable

53. OUTCOMES
Failing fistulas:
Technical success rate (<30% residual stenosis) is 80-98%
Hemodynamic success rate (normalization of flow/pressure) is 70-90%
6-month primary patency is 50%; 12-month primary patency is 25-50%
Clotted grafts:
Technical success rate is 90%
3-month primary patency is 40%

54. CONTROVERSIES
Stent grafts (Flair) P h a r m a c o l og i c v s . m e c h a n i c a l
Randomized study of 90 patients (48 Pull-type advantages: No
gastropexy, 42 not) gastropexy, no balloon which can
G tube successful in 100% of pexy rupture, mushroom retention device
patients very effective
G tube failed (placed into peritoneal Pull-type disadvantages: Sometimes
cavity) in 10% of non-pexy patients hard to snare wire in
Excoriation or pain seen around pexy stomach, chance of abdominal wall
site in 10% of pexy patients infection, may be harder to convert
Increased number of punctures can to GJ
increase bleeding risk

55. TROUBLESHOOTING
Tu b e o c c l u s i o n Tu b e l e a k a g e
1. Flush with water or saline 1. Secure disc so that balloon is well-
2. Flush with Coca-Cola apposed to inner margin of stomach
3. Pass a wire under fluoro 2. Ensure that balloon is not
obstructing gastric outlet
4. Replace tube
3. Antacids
4. Local antibiotic ointment
5. Paracentesis (if ascites)
6. Upsize tube
7. Use suture to tighten tract