This document discusses the history and development of ultrasound-guided needle procedures from the 1960s onwards. It notes that while early studies showed minor risks, later reviews found complication rates up to 0.9% with some mortality. The document outlines key aspects of performing biopsies safely and effectively using ultrasound guidance, including appropriate patient preparation, informed consent, needle choice, and specimen handling. It emphasizes the importance of real-time visualization to target lesions precisely while avoiding vital structures.

1. Presented by: Syed Yousaf Farooq

2. INTRODUCTION AND HISTORICAL
BACKGROUND

3.  The “First World Congress on Ultrasonic
Diagnostics in Medicine” was held in Vienna in
1969.
 Only two papers dealt with the capabilities of
ultrasound-guided needle procedures, and
both reflected the full spectrum of possible
procedures and future diagnostic applications.
 The only imaging modality available at that
time for the percutaneous biopsy of
nonpalpable organs and structures was
classical radiography. But this method was
problematic for several reasons.

4.  Kratochwil described in his paper how
ultrasound guidance could make standard
needle procedures easier and safer (here, by
avoiding the placenta), even in unusual
situations.
 The sectional images produced by
ultrasonography enable the target site to be
visualized and localized in all three
dimensions.
 As early as 1961,G. M. Berlyne suggested that
the two-dimensional pyelogram obtained
before percutaneous renal biopsy could be
supplemented by an A-mode scan to measure
the depth from skin to target.

5. RISKS OF
INTERVENTIONAL
ULTRASOUND

6.  The risks of percutaneous biopsies were known
and had been described in principle even before
the age of interventional ultrasound.
 Today they are still an important consideration in
the development and practice of interventional
sonography.
 While initial studies showed no serious side effects
associated with the use of needles less than 1mm
in diameter, publications over the years
documented repeated instances of serious
complications and even deaths, mostly in
individual case reports.
 Subsequent doctor surveys and reviews of the
literature indicated a mortality rate between
0.001% and 0.096% with complication rates up to
0.9%.

7. Interventional Materials and
Equipment

8. Milestones in the development of biopsy
techniques

9.  The needle tip is directed, in real time, along the
biopsy path and visualized within the lesion
 Greater precision is obtained; needle guidance is
essential for all small lesions and lesions at depth
 Fewer needle passes are required to obtain the
desired result
 The best route can be utilized and vital structures,
such as blood vessels, avoided
 b Post procedure complications, such as
haematoma, are minimized.

10.  All the advantages of ultrasound over other
imaging methods apply (quick, direct vision,
no radiation hazard, low cost). The limitations
due to bone and air-filled structures also apply.
 The capability to perform bedside procedures
for critically ill patients and to use in
conjunction with other imaging techniques, for
example fluoroscopy, is advantageous
 With ultrasound the biopsy procedure is quick,
safe and accurate and is therefore acceptable to
the patient.

11.  Contraindications are relative and include the
biopsy pathway, an uncooperative patient and
uncorrectable coagulation and should be
assessed on an individual basis.

12.  The choice of method depends upon the procedure
in question, equipment and the experience and
skill of the operator
 BLIND BIOPSY:
 With this method a position on the skin surface is
marked overlying the organ or lesion to be
biopsied, using ultrasound to localize. This
remains acceptable for diffuse disease, when only a
representative sample of liver tissue is required.
 Nevertheless, it is good practice even in these
situations to visualize the needle during the
procedure, and this method of biopsy is now used
less frequently.

13.  Most manufacturers provide a biopsy guide which fits
snugly on to the transducer head and provides a rigid
pathway for the needle
 The fixed biopsy guides contain a groove for a series of
plastic inserts ranging from 14G to 22G size, depending
on the size of the biopsy needle. It is often preferred to
use one size greater than the needle, that is a 16G insert
for an 18G needle, as the needle tends to move more
freely.
 The needle pathway is displayed on the ultrasound
monitor electronically as a line or narrow sector,
through which the needle passes.
 The operator then scans in order to align the electronic
pathway along the chosen route, the needle is inserted
and the biopsy taken.

14. Series of plastic inserts (A) range in size from 14 to 22G.
The appropriate insert is inserted into a fixed biopsy guide (B).
The procedure is performed with sterile jelly (C)
and a sterile probe cover (D) if required.

15.  A freehand approach, in which
the operator scans with one
hand and introduces the needle
near to the transducer with the
other, may be used for larger or
more superficial lesions. This
technique is commonly used
for breast biopsy and biopsy in
the head and neck.
 The needle is inserted from
one end of the probe at right
angles to the ultrasound beam;
generally speaking the angle
utilized is shallow in
comparison with the fixed
guide systems for deeper
structures.

18. NEEDLE SYSTEMS
NEEDLE TECHNOLOGY

19.  Biopsy needles have a sharp, beveled tip that
cuts the tissue when the needle is advanced.
They enter the body more easily than a sharp-
pointed needle without a cutting edge, which
would damage the tissue and cause
considerably more pain.
 Needles with an outer diameter < 1mm are
classified as “fine” needles; larger-caliber
needles with an outer diameter of 1mm or
more are classified as “coarse.”
 Various systems are available for designating
needle size. Needle diameters are most often
stated in terms of millimeters or gauge.

20.  The most popular unit for designating outer
needle diameter is gauge, which is based on the
America Wire Gauge (AWG) system.
 the higher the gauge number, the thinner the
needle. For example, a 19-gauge needle is classified
as “coarse” while a typical “fine” needle would be
22-gauge.

21.  Needle lengths from 10 to 22cm are most
commonly used.
 In principle, an excessive needle length is
unfavorable only if the target site is only 1 to 2cm
deep, as this would make the long needle unstable.
 In all other cases it is best to add a certain reserve
length to make sure the needle will be long
enough.
 A 22-gauge needle is sufficient for aspirating
watery exudates or transudates, while an 18-gauge
or larger needle should be used for pus.
 Tissue can be sampled by aspiration biopsy or by a
cutting or core biopsy technique.

22.  Because all percutaneous interventions are
invasive procedures, they require prior informed
consent that should include full disclosure of the
benefit of the procedure and potential
complications (risk), which are documented in
written form.
 In emergency situations such as with a septic
patient, it may be necessary to deviate from this
policy.
 Informed consent on the examination table is
inadequate.
 The patient may not fully understand the need for
the intervention. Consequently, time for
explanations should be allotted in the
preprocedure protocol.

23. . Aspiration
. Drainage
. Biopsy

24. . Cysts are very common.
. Usually be diagnosed accurately with ultrasound.
. In most women, they do not usually require any
intervention or follow-up.
 Cyst aspirations are done when :
. Causing significant tenderness
. The diagnosis of a cyst remains in question following the
ultrasound

25.  POSITION:
 The patient lie on her back
or slightly turned to one
side with the arm placed
comfortably under the
head.
 The skin is cleaned ,
numbed with topical
anesthesia. Using
ultrasound guidance, a
small needle is advanced
into the cyst and suction is
applied to draw the fluid
out, causing the lump to
collapse.

26. INDICATIONS:
 Icterus/liver enzyme elevation/elevated bile acids
Focal nodules or masses anywhere
 Renal disease sometimes (i.e. renal dysplasia,
renal masses, lymphosarcoma suspects)
Prostatomegaly
Free abdominal fluid
Cysts

28.  Ultrasound guidance is an accurate and reliable
biopsy guidance technique and is the method of
choice and suitable for all breast lesions visible on
ultrasound.
BREAST BIOPSY INDICATIONS:
 Focal mass or other lesion of unknown nature –
palpable or non-palpable
 Architectural distortion
 Micro-calcifications
 Cyst aspiration

29.  The long axis of the needle, should be visible
along the long axis of the transducer.
 Occasionally, during an FNA biopsy or
cyst aspiration, the transducer can be
rotated 90 degrees to visualize the
echogenic dot of the needle within the
lesion.

31.  A written request form from a medical
practitioner with the results of any previous
investigations should be available. The reason
for biopsy should be appropriate
 Assessment of blood clotting status. Normally
the prothrombin time should be within 8-12sec,
platelet count > 75 000/ml and international
normalized ratio (INR) < 1.3
 Identification of possible contraindications to
biopsy, for example an uncooperative patient,
coagulopathy.

32.  Careful explanation of the procedure to the
patient, including risks and benefits
 Appropriate measures should be taken to
preserve pre-, peri- and post procedure sterility
 A prebiopsy scan to identify a suitable biopsy
route avoiding vital structures.
 Satisfactory care of the patient both during and
after the biopsy procedure with relevant
observations of vital signs
 Appropriate preparation of the specimen.