Pulmonary interventional radiology techniques

By
Mahmoud E. Abo El-Magd
Assistant lecturer of pulmonary and critical
care medicine
PULMONARY
INTERVENTIONAL
RADIOLOGY

INTRODUCTION
PUL.INTERVENTIONAL RADIOLOGY 2
• Minimally invasive
• Image guided procedures
• Less complications
• No need for general anesthesia
• No surgical interference
• Patients with co-morbidities
• Patients refused surgery

PERCUTANEOUS TRANSTHORACIC
NEEDLE BIOPSY
• Percutaneous lung biopsy was first described by Leyden in 1883
to establish the infectious nature of lung disease.
• Actually percutaneous tissue sampling of a pulmonary, pleural or
mediastinal lesion is indicated, when histological diagnosis will
further influence diagnostic strategy and therapeutica options, or
modify tumor staging and the sequence of cancer treatment.

VALUE OF PTNB
• Cost efficiency by shortening hospital stay .
• Management was altered in 51% of patients.
• Surgery was avoided in 83% of biopsies that altered patient
treatment.

INDICATIONS
• pulmonary nodule(s) without specific diagnostic criteria on CT
ascertaining benignity .
• pulmonary nodule(s) or mass suggestive of malignancy, when
surgery will be postponed, or replaced by chemotherapy and/or
radiotherapy.
• pulmonary nodule(s) in a patient with a history of
extrapulmonary primary malignancy and in clinical remission or
presenting several primary malignancies .

• Residual non-regressive lesion following radiotherapy or
chemotherapy .
• Mediastinal mass or adenopathy. PTNB is a useful alternative to
mediastinoscopy or mediastinostomy for tissue diagnosis of
enlarged hilar or mediastinal lymph nodes.
• All areas of the mediastinum are accessible to PTNB. The
technique is faster, better tolerated and less expensive .

• Chronic diffuse pulmonary infiltrate in selected cases .
• Intracavitary injection for treatment of aspergilloma .
• Percutaneous brachytherapy of pulmonary malignancy

CONTRA-INDICATIONS
• Vascular structures such as aneurysm or pulmonary
arteriovenous malformation.
• Hydatid cyst and mediastinal pheochromocytoma are absolute
contra-indications of PTNB.

Relative contra-indications:
• puncture of both lungs during the same day.
• puncture of only one functional lung.
• chronic respiratory insufficiency.
• pulmonary arterial hypertension.
• cardiac insufficiency, recent myocardial infarct.
• severe emphysema and bullae near the pulmonary lesion.
• A coagulation defect .
• Cough, dyspnea and uncooperative patient.
• Mechanical ventilation .

TECHNIQUE
• The needle path should avoid traversing intercostal vessels (i.e.
needle entry is optimally defined at mid intercostal space).
• Central tumor necrosis is recognized on the basis of central low
densities after i. v. contrast injection.
• The biopsy needle should be directed to the viable tumor
component situated at the periphery of the lesion.

TECHNIQUE - cont
• Mediastinal and hilar vascular structures surrounding a lesion
are recognized with contrast enhanced CT.
• Real time-CT (fluoro-CT or continuous CT) is now becoming
widely available .
• US can be used as a guidance for puncture of pleural or
subpleural lesions

RESULTS
• PTNB has an accuracy varying from 80 to 95 in confirmation of
malignancy
• In a comparative study, sputum and bronchial aspiration alone
were diagnostic of cancer in 5.4%, PTNB alone in 72.6%
• false negative diagnoses are obtained in about 5% and are
caused by inadequate sampling, tumor necrosis, crushed cells,
or errors in sampling reading.
• If the sampled material is inadequate, or insufficient or in case

COMPLICATIONS
• Pneumothorax is the most frequent complication following
PTNB, with an incidence of 8-60%.
• Less than 5% of patients have persistent clinical symptoms and
require aspiration or drainage.

Factors influencing pneumothorax are :
• Age.
• Co-operation.
• respiratory function.
• biopsy technique.
• experience of the operator.
• duration of the procedure.
• number of needle passes.
• diameter and flexibility of the
needle.
• Emphysema.
• difficult localization of the target.
• depth and diameter of the target.
• mechanical ventilation.
• cavitary lesion.

• Special care should be taken in patients who underwent thoracic
surgical intervention with a potential communication between
both pleural spaces, increasing the risk of bilateral
pneumothorax.
• Best prevention of complications is to perform the procedure
rapidly and to reduce the number of passes by inspecting the
quality of smears or fragments after each puncture.

• Pneumothorax is further prevented by the roll-over technique,
which consists of turning the patient following biopsy for 15-30
minutes on the side which had been punctured.
• All patients are maintained in the recumbant position for 4
hours after biopsy; then an erect chest radiograph is obtained.
If no pneumothorax is present, compliant patients can be
discharged.

• biopsy is completed before the pneumothorax is treated. In the
literature, small bore catheter drainage of iatrogenic
pneumothorax is successful in 75-97 % .

• To reduce the risk of pneumothorax or pulmonary hemorrhage
during mediastinal biopsy, injection of small amounts of saline
with a small gauge needle can be used to distend the extra-
pleural tissue, which allows access to most mediastinal lesions,
using an exclusive extrapleural pathway without transgression
of the visceral pleura .
• Similarly, extrapleural injection of saline displaces the pleura,
allowing for a safe transpleural access to subpleural pulmonary
lesions

• Haemoptysis or hemorrhage is encountered in less than 10% of
PTNB, most of which are not life threatening
• A limited perinodular alveolar haemorrhage is commonly
observed on CT and can obscure the nodule, rendering further
punctures impossible

Other complications :
• mediastinal emphysema.
• thoracic wall haematoma.
• Haemothorax.
• cardiac tamponade.
• Empyema.
• bronchopleural fistula.
• lung torsion and implantation metastasis along the needle tract.
• air embolius and sudden death are rarely observed .
• Mortality rate of PTNB is estimated at 0.02 % .
• thoracic pain.
• pleural effusion.
• superinfection.

• Thoracic fluid collections of various origin, located in the pleura,
pericardium, lung or mediastinum can be aspirated or drained
percutaneously with imaging guidance.
• Percutaneous therapy is an important refinement compared to
blind bed side technique and compares favourably with surgery.
• Diagnostic fluid aspiration includes cytological, bacteriological
and chemical analyses.

• Fluoroscopy, US and CT can be used as guidance modalities,
either alone or in combination.
• The choice of imaging technique depends on technical
characteristics, availability, location of the collection, and
operator expertise.
• Loculated pleural effusions may be treated by thoracocentesis,
thoracoscopy, surgically or CT-guided thoracostomy tube
drainage, open drainage, or thoracotomy and pleural
decortication. Imaging guidance best insures proper catheter
positioning.

GUIDANCE MODALITIES -
ULTRASONOGRAPHY (US)
• US is particularly indicated to guide bedside percutaneous
aspiration and catheter drainage of pericardial and pleural fluid,
even of reduced amount .
• Pulmonary abscesses that are located in a subpleural location
can also be included.
• Percutaneous approach is performed in the position that
optimally displays access to the fluid collection.

COMPUTED TOMOGRAPHY
(CT)
• CT offers exquisite anatomical display of all thoracic structures
and allows percutaneous access to all spaces with equal ease
• The optimal percutaneous entry point to a pulmonary abscess is
defined according to its pleural contact, location of fissures and
vascular structures.
• CT is the optimal modality to confirm pneumothorax or
pneumomediastinum following a percutaneous procedure.

• CT is particularly useful for the percutaneous approach to the
mediastinum, and for pulmonary abscesses with a reduced
pleural contact.

• Pleural empyema
• Malignant Pleural Effusion
• Post-traumatic Haemothorax
• Gazeous Collections
• Pulmonary Abscess
• Mediastinal collections
• Pericardial Fluid Collection
• Percutaneous Drainage of Tension Pneumomediastinum

COMPLICATIONS OF PERCUTANEOUS
CATHETER DRAINAGE
• Complications occur in approximately 5% and are mainly due to
inadequate catheter insertion technique
• Injury to an intercostal artery can produce a haemothorax or a
haematoma of the thoracic wall.
• Life threatening haemorrhage is rare, but can be observed
following rupture of the wall of a pulmonary abscess, erosion of
a branch of the pulmonary artery or transfixation of an internal
mammary or mediastinal vessel by the catheter.

• When normal lung is crossed with a large bore catheter using
the trocar technique, a pulmonary infarction can result.
• Haemoptysis can occur during catheter insertion. Pneumothorax
is a potentially frequent complication.
• Other side-effects include subcutaneous emphysema, local skin
infection at the entry point of the catheter and discomfort during
breathing, rib erosion, catheter leakage, bending, breakage and
obstruction.

• Although IV TPA is indicated for treatment of acute massive PE,
many patients cannot receive systemic thrombolysis due to
contraindications.
• The rate of major hemorrhage from systemic thrombolytic
administration is approximately 20%, including a 3%–5% risk of
hemorrhagic stroke .
• In a meta-analysis of 594 patients with acute massive
PE treated with modern CDT, clinical success was achieved
in 86.5%.

• Pulmonary angiography in a 57-year-old woman in shock from
acute bilateral massive PE. Initial right (a) and left
(b) pulmonary angiograms show near-complete obstruction.
Pulmonary artery pressure was 73/18 mm Hg. Final right (c) and
left
(d) images after suction thrombectomy and catheter-directed
thrombolytic agent injection into each main descending
pulmonary
artery. Pulmonary artery pressure was reduced to 36/16 mm Hg.
(Images courtesy of Daniel Y. Sze.)

• Biopsy – guided biopsies
• Embolization
• Vascular embolization
• Chemo-embolization
• Radio-embolization
• Radiofrequency ablation
• cryoablation

 definitive treatment of benign lesions.
 reducing the risk of bleeding prior to biopsy or surgery.
 palliation of pain, bleeding, fever, and hypercalcemia-like symptoms
in inoperable tumors.
 preventing further dissemination of a tumor.
 increasing the response to chemotherapy and radiotherapy.
 retention of selectively delivered anti-mitotic agents or monoclonal
antibodies deep into the tumor substance.

EMBOLIC AGENTS
• Nontoxic
• Sterile
• Radiopaque
• easy to prepare or to obtain
 gelatin sponge
 polyvinyl alcohol (PVA) particles
 liquid (absolute alcohol)
 Coils
 tissue adhesives
 Ethanol
 microfibrillar collagen
 autologous blood clot

ADVANTAGES
• Minimal incisions/scarring
• Shorter hospital stay/outpatient
• Reduced recovery time
• Anesthetic
• Lower risk of complications
• Treatment option in poor/risk prone patients

DIAGNOSTIC TESTING – pulmonary angiography
• Pulmonary angiography generally is no longer necessary as a
diagnostic procedure alone.
• It is reserved for therapeutic purposes after a diagnosis has
been established.
• It remains the gold standard for inconclusive cases.

TREATMENT AND MANAGEMENT
PERCUTANEOUS TRANSCATHETER
EMBOLIZATION
• Percutaneous TCE is the gold standard for the treatment of
PAVM because it is effective in reducing the risk of paradoxical
embolism and other complications associated with PAVM.
• less invasive and easy to repeat .
• disadvantages include collateralization and revascularization
over time.

EMBOLIZATION
• Major indications for treatment are :-
- prevention of neurologic complications, including stroke and
cerebral abscess from paradoxical embolism.
- improvement in exercise tolerance .
- reduction in migraine prevalence .
- prevention of lung hemorrhage.

EMBOLIZATION
• During embolization, the supplying artery immediately preceding
the PAVM is the target to occlude the feeding vessel just
proximal to the aneurysmal sac .
• The deployed coils are designed to coil within the vessel lumen
and carry micro fibers that activate platelets to generate an
occluding platelet plug.

EMBOLIZATION
• Amplatzer vascular plugs (AVPs) and balloon devices provide
direct obstruction to vascular flow.

EMBOLIZATION

EMBOLIZATION
• Recanalization and collateralization of the post-embolization
PAVM can present in the range of 5% to 20%.
• No device appears to be superior in preventing recanalization.
• Study of 28 PAVMs showed that recanalization did not develop
between 6 and 40 months in patients treated with AVP and coils.

INTERVENTIONAL RADIOLOGY
• Today there are several radiological treatments that can be used
in both traumatic and non-traumatic chylothorax .
• Much more experience is available for percutaneous
embolization of the thoracic duct , which can be performed as
an alternative to thoracic duct ligation and can be performed in
both adults and children .
• Embolization has a much higher success rate: if the thoracic
duct can be intubated successfully, the procedure is successful
in well over 90% of cases

• Fiber-optic bronchoscopy (FOB) is widely used to diagnose
various lung diseases, especially endobronchial lung lesions. It
gives diagnostic yields as high as 70-90%
• peripheral non-endobronchial lung lesions have been and
continue to be a challenge to clinicians.
• Without accurate localization, the diagnostic yield of
transbronchial lung biopsy (TBBx) is limited and variable,
ranging from 16-80%.

• For nonvisible or peripheral lesions, conventional techniques
such as selective bronchial aspiration or broncho-alveolar
lavage have a diagnostic yield of only 48%.
• The addition of other diagnostic procedures such as
transbronchial needle aspiration or bronchoscopic lung biopsy
(BLB) increases diagnostic yield to more than 70% when used
in combination or when guided by fluoroscopy.

• Fluoroscopy reduces the risk of pneumothorax during TBBx
• FOB FB extraction fluoroscopic guided.

• Most patients either have too alimited pulmonary function for
surgical resection or are unable to tolerate surgery because of
other comorbid medical conditions, especially patients with poor
cardiopulmonary functions.
• Image-guided percutaneous thermal ablation therapies
are minimally invasive interventional techniques

• Among these techniques, radiofrequency ablation (RFA) has
now attained consideration for therapy of primary and secondary
lung tumors .
• Others include cryoablation , laser , and more recently
microwave .
• Thermal ablative techniques produce irreversible tumor tissue
destruction through application of either hot or cold thermal
energy.

• Planning, monitoring, targeting, and controlling this
modality are performed with the help of different imaging
modalities, including ultrasound, X-ray, computed tomography
(CT), and magnetic resonance tomography.

Pulmonary interventional radiology techniques

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