This document provides guidance on performing interventional radiology procedures using ultrasound guidance. It discusses selecting an optimal puncture site using ultrasound to identify the shortest skin-target distance and avoid vital structures. Real-time ultrasound visualization allows monitoring of the needle trajectory. Procedures are usually done on an outpatient basis if the patient is cooperative with a family member present. Precautions like fasting and stopping anticoagulants beforehand are recommended. Ultrasound probes and materials must be properly sterilized. The "free-hand" technique allows real-time adjustment of the needle angle under ultrasound guidance. Biopsy needles vary in size and shape depending on the target tissue and goal of obtaining cytology or histology samples. Potential

1. INTERVENTIONAL RADIOLOG
DR M.KILANI,MD,LILLE,FRANCE
ULTRASOUND & CT

2. Puncture sites
Access:
•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 simulate
biopsy moment
Advantages 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.

3. Interventional Ultrasound
Always Avoid AVOID IF POSSIBLE
Large vessels, Bowel
proximal organ vessels Liver
Ureter! Distal vessels
Gallbladder
Parenchymatous
organs:kidney, spleen,
pancreas

4. CONDITIONS OF REALISATION
One day Hospitalization
Ambulatory (if cooperative, family at home, classical technique)
Fasting
Clinical and imaging data
- platelets >150 000
- PT >70 %s
- TCA < 2x Normal
Stop anticoagulant TTT 8 days before.
Sédation - anxiolytic 2 hrs before
No sleeping patient!!

5. 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)

6. 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

7. 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)

8. GUIDANCE METHOD
Biopsy Kit :
Adaptable systeme on the probe: visualization of target and
needle trajectory
“ Free-hand” Technique :
Probe is positioned at the entry point with needle along axis of
US beam allowing visualisation of the whole length of the trajectory
(abdominal).
Always visualize your entry path
with real-time needle progression

9. 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

10. 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

11. Interventional Ultrasound
Lateral decubitus
Intercostal approach! Scalpel Orientation when doing skin incision

12. Needles
Many varieties
Different sizes, calibers, form, shape and nature of the procedure
• Cytology : Chiba needle, Franseen
• Histology : Bard needle

13. Needles
Many varieties

14. 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

15. ‘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

16. 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

17. Liver
Increased hemorragic risk if hemangioma puncture
Fill the needle track with Gelfoam

18. 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

19. GUERIDON PRELEVEMENT
Sterile table
1 gauze
1 ampoule of normal saline (moisten biopsy)
1 bottle of Formol or wet gauze
If drainage : tubes of bacteriology for culture & sensitivity

20. 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.

21. COMPLICATIONS
Complications are rare (0,008% à 0,03 %)
-Vasovagal attack
Severe complications
- hemorrhage, arterio-veinous fistula, hematoma and
pneumoperitoneum (liver)
- Acute pancreatitis if normal pancreatic tissue
- Metastatic seeding of the needle track.