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Invasive Radiology

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Title: Invasive Radiology


1
Invasive Radiology
  • Dr. Fern Karlicki
  • (the one who LIKES to put needles in people at
    St. Boniface Hospital)

2
Invasive Radiology
  • After this workshop, participants should be
    familiar with
  • Common imaging guided procedures
  • Patient preparation prior to a procedure
  • Post procedure complications

3
Invasive Radiology
  • 10 of Rads do procedures
  • 96 of procedures are done with US guidance
  • US is cheap, portable, quick, involves no
    radiation, and gives superior diagnostic yields
    (87 vs 77 ) compared to CT
  • CT used when US cant see lesion
  • Technical, air, obesity, bone

4
Common Imaging Guided Procedures
  • Solid organ biopsy - random core of liver and
    renal most common
  • Biopsy of masses fine needle or core
  • Breast , liver , thyroid , kidney , pancreas , GB
    , nodes , ovary , bowel , MSK , etc

5
Common Imaging- Guided Procedures
  • Thoracentesis / chest tube insertion
  • Abscess / fluid collection - asp or drain
  • Ascites asp or drain
  • GB/biliary drain
  • Nephrostomy tubes
  • Cyst asp

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Imaging guided Procedures
  • General preparation
  • Informed consent
  • Local anesthetic
  • Aseptic technique
  • Sedation rarely needed (endovaginal drainages
    are the exception - ALWAYS done with conscious
    sedation
  • Safest pathway - not always the shortest

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Procedures that require little or NO Special Prep
  • Breast biopsies
  • Superficial biopsies and aspirations e.g. ant
    abdominal wall or extremity mass / fluid
    collection
  • Paracentesis
  • Thyroid biopsies - D/C anticoagulants /- ASA
    / NSAIDS ? D/C Plavix if safe

11
Preparing your Patient for all Deep Organ
Procedures
  • Fasting 6 hours
  • Stop ASA / NSAIDS 1 week prior (some say only for
    renal / spleen bx)
  • Stop Plavix 3-5 days prior - ONLY IF SAFE re
    coronary artery stent
  • Stop warfarin 3-5 days prior (INR lt 1.5)
  • Stop heparin 6 hours prior
  • Stop LMWH 12 hours prior

12
Parameters for Deep Organ Biopsy
  • INR lt 1.5 2
  • Platelets gt 50,000 - how they function is
    important
  • Hb - we just need a value
  • Bleeding time on dialysis patients
  • PTT lt 40

13
Fine needle or Core??
  • Core biopsies with automated device
  • Minimum 1.5 cm throw - 14-22G
  • More info than fine needle
  • More bleeding risk
  • More risk of non-target organ injury
  • Fine needle ( /- aspiration)
  • Thyroid , liver , pancreas , lymph nodes
  • Good for small lesions in tight spaces

14
Drainage Catheters
  • 8.5 french or larger
  • Self locking pigtail
  • Secured at the skin
  • They still fall out
  • Uncomfortable
  • Aspiration may be preferable

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General post - procedure Complications
  • Infection rare
  • Vasovagal
  • Pain
  • Bleeding
  • Non target organ injury

17
Post Procedure Monitoring
  • Only needed for deep organ biopsy
  • Bed rest and vital signs 2-5 hours after
  • Observe total of 3-6 hours

18
  • THERE IS AN
  • EPIDEMIC
  • OF THYROID NODULES
  • REQUIRING
  • BIOPSY!!!!!!

19
Thyroid Nodules
  • In the past, only palpable thyroid nodules would
    undergo biopsy
  • Now, many small non-palpable nodules are
    discovered on CT or US done for other reasons

20
Thyroid Nodules
  • 50 of people have thyroid nodules
  • The vast majority (90) are benign
  • Tiny, clinically insignificant cancers can be
    found at autopsy in up to 50 of people
  • The incidence of thyroid cancer has doubled in
    the last 20 years yet mortality is unchanged

21
Thyroid Nodules
  • WHO to biopsy?
  • Head and neck radiation
  • Family history
  • lt30 yo
  • gt60 yo
  • Male
  • Firm, fixed, growing
  • Lymphadenopathy

22
Thyroid Nodules
  • WHAT to Biopsy?
  • gt 1 cm solid microcalcifications
  • gt 1.5 cm solid
  • gt 2 cm complex cystic
  • The largest is NOT ALWAYS the cancer - 30 of
    cancers will be a non dominant nodule
  • In MNG need to pick the scariest

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Thyroid Biopsy
  • Local anesthesia
  • 25 g - capillary - multiple passes
  • Target solid vascular portion
  • 70 satisfactory
  • 20 inconclusive
  • 5-10 unsatisfactory

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Thyroid Biopsy Complications
  • Biggest one is not getting an answer!!!
  • Follow??
  • Re biopsy??
  • Core biopsy more bleeding
  • Bleeding
  • Airway compromise rare
  • Non-target organ injury

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Core Renal Biopsy in Renal Failure
  • Riskiest biopsy we do
  • 14-16 g
  • Renal blood flow
  • Vasculitis
  • High BP
  • Prolonged bleeding time
  • Chronic component with fibrosis

31
Core Renal Biopsy in Renal Failure
  • We need these patients BUFFED
  • Need to D/C EVERYTHING that can thin the blood
  • Nephrology consult to determine need for biopsy

32
Core Renal Biopsy Complications
  • 90 have a perinephric hematoma
  • Average hemoglobin drop is 2 gms
  • 20 have transient gross hematuria
  • 15 develop AVF that leads to ongoing hematuria
    but few need embolization

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35
Renal Mass Biopsy
  • Epidemic of incidental renal mass detection
  • More than 50 of these incidentalomas are benign
  • Biopsy is evolving as a way to avoid unnecessary
    nephrectomy

36
Renal Mass Biopsy
  • Urologist consult
  • Most useful for
  • Suspected lymphoma
  • RCC vs mets
  • Confirm unresectable RCC
  • Oncocytosis
  • lt 3 cm masses
  • Complex cystic masses
  • Infection

37
Renal Mass Biopsy Technique
  • 18 g co-axial
  • 1.3 bleeding complications e.g. hematomas
    needing transfusion AVF / pseudoaneurysm
  • No tumor seeding
  • 95 diagnostic

38
Core Breast Biopsy
  • 14 g
  • 2-6 passes
  • 95 accurate
  • Fibrous and heterogenous lesions may need
    re-biopsy, follow-up or sx
  • Specific complication of lung perforation

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Liver Biopsy
  • Random core 18 g for HC/HB/HIV autoimmune
    hepatitis etc
  • Targeted lesion - fine needle or core
  • The larger the needle the higher risk of bleeding
    especially for sub-capsular lesions or in the
    face of cirrhosis

42
My Motto
  • You can stick a 22 g needle just about anywhere
    with impunity
  • A biopsy is often the shortest, quickest,
    cheapest and most efficient way to an answer when
    imaging is unlikely to be 100 definitive

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