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Interventional Radiology Percutaneous Catheters Indications, Techniques

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Interventional Radiology Percutaneous Catheters Indications, Techniques & Management By Dr. Steve J. Lengle, MD Disclosure: Dr. Lengle has no financial interest in ... – PowerPoint PPT presentation

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Title: Interventional Radiology Percutaneous Catheters Indications, Techniques


1
Interventional Radiology Percutaneous
Catheters Indications, Techniques Management By
Dr. Steve J. Lengle, MD
Disclosure Dr. Lengle has no financial interest
in any of the products or manufacturers
mentioned.
2
Interventional Radiology
  • Interventional radiology is the medical specialty
    devoted to advancing patient care through the
    innovative integration of clinical and
    imaging-based diagnosis and minimally invasive
    therapy. Compared to surgery, IR has shorter
    recovery times and is less painful and less
    risky.

3
Interventional Radiology Percutaneous Catheters
  • The ideal management of percutaneous drainage
    catheters require three distinct categories of
    care
  • 1. Expert staff for evaluation and management of
    placement of appropriate size and type of
    catheter (if indicated).
  • 2. Close management of function,
    dressing/catheter position stability and
    sterility
  • 3. Appropriate evaluation for exchanging,
    upsizing, downsizing or removing catheter

4
Gastrointestinal Intervention
  • Case 1
  • A 69 year old female is status post CVA. She has
    a long history of gastroparesis and GERD. During
    her swallowing evaluation, she shows free
    aspiration with all consistency of ingested food.
    What would be the best and safest long-term
    feeding tube for this patient?
  • Percutaneous Gastrostomy
  • Percutaneous Gastrojejunostomy
  • Surgical Jejunostomy
  • Nasojejunal tube
  • Nasogastric tube

5
Gastrointestinal Intervention
  • Gastrostomy Tube

6
Gastrointestinal Intervention
  • Indications for gastrostomy (G) or
    gastrojejunostomy (GJ) tube placement
  • Gastrostomy Tubes
  • Nutrition
  • Dysphagia
  • Cerebral vascular accident (CVA)
  • swallowing dysfunction
  • Ear, nose, throat (ENT) or neck malignancy
  • Dementia
  • comatose state

7
Gastrointestinal Intervention
  • Gastrostomy Tubes
  • Small bowel disease
  • Crohn's disease
  • Short gut syndrome
  • Gastric Decompression
  • Gastroparesis
  • Ileus
  • Obstruction secondary to malignancy

8
Gastrointestinal Intervention
  • Gastrojeunostomy tube

9
Gastrointestinal Intervention
  • Gastrojejunostomy Tubes (Same as gastrostomy
    tubes, plus)
  • Poor gastric emptying
  • Diabetes mellitus (DM) - gastroparesis
  • Partial gastric outlet obstruction
  • Gastroesophageal reflux (GER)
  • CVA
  • Trauma
  • Children (more common than adults, but not
    universal)

10
Gastrointestinal Intervention
  • Whether feeding tube should terminate in the
    stomach (G tube) or in the small bowel (GJ tube)
    controversial
  • G tubes
  • Allow bolus feedings
  • more convenient for ambulatory patients
  • large lumens with less frequent occlusion
  • G tubes have been associated with
    gastroesophageal reflux (GER)

11
Gastrointestinal Intervention
  • Prospective comparison of G and GJ tube placement
    by Hoffer et al
  • GJ tube placement had decreased incidence of
    post-procedural pneumonia
  • G tube placement was faster, cost less, and
    required less tube maintenance.

12
Gastrointestinal Intervention
  • Contraindications G/GJ tube placement
  • Absolute
  • S/P total gastrectomy
  • Gastric carcinoma
  • Uncorrectable coagulopathy
  • Relative
  • Ascites/Peritoneal dialysis
  • Gastric varices
  • Overlying viscera
  • Complex previous abdominal surgery.

13
Gastrointestinal Intervention
  • Ascites considered relative contraindication G /
    GJ tube
  • Fluid displace the stomach from abdominal wall
  • puncture difficult potentially dislodging the
    catheter following placement
  • high incidence of peri-catheter leakage following
    the procedure
  • Ultrasound guided paracentesis prior to
    procedure/with gastropexy
  • Reduce incidence peri-catheter leakage catheter
    dislodgement

14
Gastrointestinal Intervention
  • Prior partial gastrectomy can make G tube
    placement more difficult
  • Does not contraindicate the procedure
  • tube placement in patients partial gastrectomy
    can be performed successfully with only minor
    modifications of the standard procedure

15
Gastrointestinal Intervention
  • Results six recent large series fluoroscopy
    guided percutaneous gastrostomy /
    gastrojejunostomy tube placement
  • Technical success 95 to 100
  • Most reporting technical success rates 99
    better
  • 30 day mortalities adult patients 3.8 to 26,
  • mortality attributable to procedure 0-2.
  • The major complication rate(including
    peritonitis, hemorrhage, tube migration, and
    sepsis) ranged from 0-6,

16
Gastrointestinal Intervention
  • minor complication rates 3 to 21
  • pain without peritoneal sign
  • external catheter leakage
  • stomal infection
  • asymptomatic catheter migration
  • leakage of ascitic fluid
  • late tube dislodgement

17
Gastrointestinal Intervention
  • These results compare favorably with those of
    endoscopic and surgical gastrostomy Wollman et
    al performed meta-analysis of over 5000 patients
    who underwent radiologic, endoscopic, or surgical
    gastrostomy
  • Fluoroscopically guided techniques were
    associated with a higher success rate than
    endoscopic gastrostomy
  • Less morbidity than either endoscopic or surgical
    gastrostomy.

18
Gastrointestinal Catheter/Insertion site Care
  • The site should be kept clean and dry. Catheter
    should be kept secure and free of tension.
  • Gastropexy buttons removed after 2 weeks
  • Gastrostomy and gastrojejunostomy tubes exchanged
    every 3 months.
  • Inadvertently removed tubes need to be replaced
    as soon as is humanly possible, the tract will
    shut down within 12-24 hours and require a new
    puncture to replace the tube.

19
Gastrointestinal Catheter/Insertion site Care
  • Localized superficial wound inflammation and
    infections can be treated conservatively with
    topical agents but closely followed and
    antibiotics administered judiciously.
  • Pericatheter leakage may require tube
    manipulation (tighten the balloon/skin disc
    device) or changing/upsizing tube.

20
Gastrointestinal Intervention
  • Gastrostomy Tube

21
Gastrointestinal Catheter/Insertion site Care
  • Only approved feedings and medications
    (suspensions and elixirs) should be placed
    through the tubes.
  • NEVER crush time release meds and place though
    tube
  • Some medications can be COMPLETELY crushed and
    dissolved then placed through tube.

22
Percutaneous GI procedures
  • Case 1
  • A 69 year old female is status post CVA. She has
    a long history of gastroparesis and GERD. During
    her swallowing evaluation, she shows free
    aspiration with all consistency of ingested food.
    What would be the best and safest long-term
    feeding tube for this patient?
  • Percutaneous Gastrostomy
  • Percutaneous Gastrojejunostomy
  • Surgical Jejunostomy
  • Nasojejunal tube
  • Nasogastric tube

23
Percutaneous Drainage procedures
  • Long term malignant effusion/ ascites management
    (Aspira/Pleurx)
  • Biliary
  • Transhepatic biliary
  • Percutaneous cholecystostomy
  • Thoracentesis
  • Paracentesis
  • Abscess / empyema drainage
  • Hematoma drainage
  • Urinary
  • Nephrostomy
  • Suprapubic cystostomy

24
Biliary Intervention
  • A 35 y/o Nuclear Engineer with a wife and 3
    children presents with painless jaundice, fever,
    pruritis and a total bilirubin of 7. CT scan
    demonstrates an infiltrating mass at the head of
    the pancreas, ERCP failed to gain access to the
    Ampulla of Vater. Attempted brush biopsy was
    inconclusive. The patient shows no evidence of
    metastatic disease.
  • The best initial procedure for this patient would
    be
  • Whipple procedure
  • Transhepatic biliary stenting with a metal stent
  • Transhepatic biliary drainage with antibiotic
    therapy followed by biopsy and surgical
    consultation
  • Hospice

25
Percutaneous Drainage procedures Indications
  • Biliary obstruction with
  • Pruritus
  • Anorexia
  • Cholangitis
  • Sepsis
  • hyperbilirubinemia
  • Antineoplastics excreted by liver

26
Biliary Intervention
  • Indications for biliary drainage/stenting
  • Decompress obstructed biliary tree
  • Jaundice
  • Anorexia
  • Pruritis
  • Cholangitis
  • Receive chemo excreted by liver
  • Access for local brachytherapy
  • Combine with dilation of biliary
    strictures/occlusions
  • Remove bile duct stones
  • Divert bile from or stent a bile duct defect

27
Biliary Intervention
  • Contraindication to biliary drainage
  • Coagulopathy is a relative contraindication
  • Risk vs benefit

28
Biliary Intervention
  • Complications (major) 2
  • Sepsis
  • Cholangitis
  • Bile leak
  • Hemorrhage
  • Pneumothorax
  • Hemothorax

29
Biliary Intervention
  • Plastic versus metallic stents treatment of
    malignant biliary obstruction
  • metallic stents have a clear clinical advantage
    in terms of patency and rates of reintervention
  • 30-day reobstruction rate is almost double for
    plastic stents
  • Some studies suggested that physical properties
    of self-expanding metal stent are preferred for
    extrahepatic biliary duct

30
Biliary Intervention
  • Expanded polytetrafluoroethylene-fluorinated
    ethylene propylene (ePTFE-FEP)-covered biliary
    endoprosthesis shown to have primary patency
    rates at 3, 6, and 12 months were 90, 76, and
    76, respectively
  • Branch duct obstruction was observed in 10 of
    their patients

31
CAT SCAN
32
Biliary Intervention
  • CT scan
  • Mass in head of pancreas
  • Dilated (Courvosier) GB
  • Intra extrahepatic biliary dilation

33
Biliary Intervention
  • Intrahepatic biliary dilation

34
Biliary Intervention
  • CT Coronal reconstruction

35
Biliary Intervention
  • Percutaneous
  • Transhepatic
  • Cholangiography

36
Biliary Intervention
  • Select best duct for drainage / geometry

37
Biliary Intervention
  • Negotiating CBD

38
Biliary Intervention
  • Negotiating CBD

39
Biliary Intervention
  • Access to duodenum

40
Biliary Intervention
  • Dilating obstructed distal CBD

41
Biliary Intervention
  • Dilating obstructed distal CBD

42
Biliary Intervention
  • Internal-External Biliary Drain in Place

43
Biliary Intervention
  • Biliary tree decompressed

44
Biliary Intervention
  • Positive CT guided biopsy for AdenoCA
  • Surgical consult X 2
  • Not surgically resectable

45
Biliary Intervention
  • Biliary tree decompressed

46
Biliary Intervention
  • Duodenal patency confirmed

47
Biliary Intervention
  • Sheath and stent in duodenum

48
Biliary Intervention
  • Bare stent deployed to maintain cystic duct
    patency

49
Biliary Intervention
  • Dilate stent

50
Biliary Intervention
  • No contrast flows to duodenum with sheath
    injection

51
Biliary Intervention
  • Coaxial deployment of covered stent

52
Biliary Intervention
  • Brisk flow into duodenum, rapid decompression of
    biliary tree and GB

53
Biliary Intervention
  • Access Maintained with 10.2 Fr internal-external
    biliary drainage catheter
  • Downsize catheter then remove in 2 weeks

54
Biliary Intervention
  • A 35 y/o Nuclear Engineer with a wife and 3
    children presents with painless jaundice,
    pruritis and a total bilirubin of 7. CT scan
    demonstrates an infiltrating mass at the head of
    the pancreas, ERCP failed to gain access to the
    Ampulla of Vater. Attempted brush biopsy was
    inconclusive. The patient shows no evidence of
    metastatic disease.
  • The best initial procedure for this patient would
    be
  • Whipple procedure
  • Transhepatic biliary stenting with a metal stent
  • Transhepatic biliary drainage with antibiotic
    therapy followed by biopsy and surgical
    consultation
  • Hospice

55
Biliary Intervention
  • Insertion site should be kept clean and dry
  • 24 hours external drainage then cap tube and
    internally drain (conserve bile salts).
  • Connect external drainage bag only to patient
    (not to bed, do not let hang free)
  • Flush catheter with 10cc NS once a day. DO NOT
    aspirate. Pulls bacteria into biliary tree.
  • Patient to return to IR if fevergt101,
    pericatheter leakage, increasing pain, increasing
    jaundice

56
Biliary Intervention
  • Change catheter every 3 months and PRN
  • Upsize for pericatheter leakage if necessary
  • Convert to internal biliary stent for malignant
    stricture if appropriate
  • DO NOT place metal stent for benign strictures
    unless life expectancy is less than 3-6 months

57
Percutaneous Drainage procedures Indications
  • Percutaneous nephrostomy
  • majority of the cases relieve urinary obstruction
  • benign or malignant nature.
  • treatment of urinary fistulas
  • Urosepsis

58
Percutaneous nephrostomy
  • Indicated if retrograde endoscopic procedure
    fails or is contraindicated
  • Place catheter with minimal manipulation (sepsis)
  • Leave to external drainage and administer
    antibiotics
  • Can attempt internalization in 7-14 days

59
Percutaneous nephrostomy
  • Keep insertion site clean and dry
  • Connect external drainage bag only to patient
    (not to bed, do not let hang free)
  • May need to flush long term indwelling
    nephrostomy or if lots of clots.
  • Change tube every three months (stone formers may
    require more frequent changes)

60
Paracentesis Indications
  • New onset ascites or ascites of unknown origin
  • Suspected malignant ascites
  • Peritoneal dialysis
  • Fever
  • abdominal pain
  • signs of sepsis
  • Patients ascites known etiology
  • Fever
  • painful abdominal distention
  • peritoneal irritation
  • Hypotension
  • Encephalopathy
  • sepsis

61
Paracentesis Contraindications
  • Uncorrected bleeding diathesis
  • Previous abdominal surgeries with suspected
    adhesions
  • Severe bowel distention
  • Abdominal wall cellulitis site puncture

62
Paracentesis Complications
  • Pain
  • Infection
  • Bleeding
  • Solid / hollow visceral puncture

63
Thoracentesis Indication
  • Diagnostic
  • Infection
  • malignacy
  • Therapeutic
  • SOB
  • Hypoxemia
  • Post thoracotomy

64
Thoracentesis Contraindication
  • Local skin infection oversite thoracentesis
  • Uncontrolled bleeding or clotting abnormality

65
Thoracentesis Complication
  • Failure to remove fluid
  • Hemothorax
  • Pulmonary hemorrhage
  • Pneumothorax 10

66
Thoracentesis Complication
  • Chest tube placement
  • Significant hemothorax
  • Symptomatic pneumothorax
  • Enlarging pneumothorax

67
Aspira/Pleurx catheter placement
  • Thoracic or peritoneal placement for management
    of malignant effusions/ascites
  • End of life comfort care
  • Life expectancy of 6 months or less

68
Aspira/Pleurx catheter placement
  • Keep exit site clean and dry
  • May drain daily if necessary
  • Up to 30 thoracic catheters cause pleurodesis
    allow removal of tube and cessation of pleural
    fluid production
  • Follow up for fever, pericatheter bledding and
    cessation of fluid

69
Percutaneous Abscess Drainage Indications
  • Empyema /Lung abscess
  • Appendiceal abscess
  • Localized
  • Diverticular abscess
  • Convert two stage surgery to one stage

70
Percutaneous Abscess Drainage Indications
  • Post surgical abscess
  • Biloma
  • Urinoma
  • TOA

71
Percutaneous Abscess Drainage (Relative)
Contraindications
  • Pt. unstable / unable to cooperate
  • No safe access (absolute)
  • Uncontrolled coagulopathy

72
Percutaneous Abscess Drainage Complications
  • Pain
  • Bleeding
  • Puncture of non-target organ
  • Malpositioned catheter

73
Percutaneous Abscess Drainage
  • Keep site clean, dry secured with tape and gauze
  • Flush 1-4 times per day 5-10 cc sterile NS
  • Keep record of output, remove tube when output is
    lt10cc/24 hours
  • Change, replace or upsize tube when dislodged or
    pericather drainage.

74
Percutaneous Abscess Drainage
  • If abscess loculated, may need to manipulate tube
    to breakup adhesions vs place additional drainage
    catheter(s)

75
Interventional Radiology Percutaneous Catheters
  • The ideal management of percutaneous drainage
    catheters require three distinct catagories of
    care
  • 1. Expert staff for evaluation and management of
    placement (if indicated)
  • 2. Close management of output, dressing/catheter
    position/stability and sterility
  • 3. Appropriate evaluation for exchanging or
    removing catheter
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