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Image Guided Procedures Pearls, Pitfalls, and Disasters

Miles B. Conrad MD, MPH Clinical Assoc. Prof of Radiology

Section: IR

Disclosures:

I have nothing to disclose

Image Guided Procedures Pearls, Pitfalls, and Disasters

• Outline: –Central venous lines

–Thoracostomy tubes and thoracentesis

–Paracentesis

Central Venous Access

• Options in difficult access cases

• Complications

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IJ Access

• Standard IR practice

– Seems to be safer than subclav for short term access

– Long term subclavian access inc rates of subclav. stenosis

– Very low chance of ptx in experienced hands

*Crit Care Med. 2002 Feb;30(2):454-60

Subclavian Access Ultrasound is almost never used…but it works well!!

Indications

• Thrombosed/occluded IJ’s • Prior CV catheters

• IVDU

• Neck infections

• Tracheostomy tubes

• C collars

Contraindications

• Ax node dissections

• Fistulas

• DVT

• Long standing catheter need

US Subclavian Access

Infraclavicular view of the Subclavian V. and A

A

V

Infraclavicular Subclavian Access

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Infraclavicular Subclavian Access Supraclavicular Subclavian Access

When attempting this, needle tip localization is of paramount importance!

Supraclavicular Subclavian Access

Why? • If you can identify subclavian v. better than

with infraclav view

• Tiny subclavian v.

• Thrombosed IJ’s

Needle tip localization is key...or this is dangerous

Supraclavicular Subclavian Access

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78 yo F w/ ESRD, failed upper extrem grafts, R pacemaker

Supraclavicular view of R subclav. V.

Supraclav subclav HD cath

IJ’s are out

Be aware of the warning signs of SVC syndrome…

Chest wall collaterals portend a difficult access

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Catheter in azygous

Catheter in azygous

• The azygous will reverse flow and enlarge in infraazygous SVC occlusion

– Very common in pts with chronic catheter pts and dialysis fistulas

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Complications

• Dilator injuries

• Malpositioned lines

• Air embolus

• Arterial puncture

• Ptx

• Loss of wire

• Infection

Kink, BC vein puncture

Malpositioned line

Catheter in Ao or L SVC?

Earlier CT

Dublicated SVC: 0.3-.5%

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RV

Seen incidentally in up to 50% pts on CT and is usually of no significance This may be a morbid/lethal issue in cardiopulmonary dz or those with R-L shunts

Air Embolus Inadvertent Arterial Line

Jumper s/p R subclav cordis placement

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R Vertebral artery

Cordis tip

R CCA

These get filled with thrombus

54 yo F s/p L chest wall resection

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Pseudoaneurysm and Brachial a. Embolus

Subclavian Covered Stent

s/p attempted R IJ placement

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Presumed alveolar-pleural fistula w/ air leak

Lung re-expanded on LCWS

Likely tear injury to pleura

Consider decreasing negative pressure until lung is up on waterseal

55 yo M w/ sepsis, s/p R IJ line

RIJ cath still around line

Wires are usually pushed in due to failure to hold the wire while advancing the dilator or catheter

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Loss of wire Wire retrieval from groin

Alternate IV site: Deep Brachial/Basilic Puncture

Basilic v.

Brachial v.

Brachial a.

. Median n.

The solution for IV access in skin poppers

Traditional angiocaths are too short!

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Pleural Drainage

• Thoracostomy tubes/Thoracentesis

– Empyema

– Efficacy of fibrinolysis of infected pleural effusions

• tPA and DNAse

• Bleeding associated with tPA

– Transcostal access techniques

• Complications – Malpositioned tubes

– Bleeding

Thoracostomy Tubes:

Small bore (6-F to 16-F)

Pigtail Catheter Large bore (18-F to 28-F)

Thalquick Catheter

Lung abscess: Avoid this!

Pleural fluid CT Underrepresents Septations

Likely will need fibrinolysis…

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NEJM 2011;365:518-26

MIST II Double Blind Trial

• 10 mg TPA alone

• 5 mg DNAse alone

• DNAse + TPA

• Saline alone

• Bid tx x 3 days

• Clamped x 1 hr

• -17+/- 24.3 (p=0.55)

• -14.7 +/- 16.3 (p= 0.14)

• -29.5 +/- 23.3 (p=0.005)

• -17.2 +/- 19.6

%Δ in pleural opacity from Day 1 to 7 on CXR

SFGH experience: 5% of patients develop severe chest pain and some required elevated level of care

tPA = bad idea

28 yo M s/p GSW to lung s/p wedge resection w/ adjacent hematoma

Massive Hemoptysis

53 yo F w/ ovarian CA

Intercostal artery injury and abdominal chest tube

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Intercostal artery embo There are many arteries to contend

with

Moore E. STR 2004 Walking over a rib does not prevent all bleeding

Supracostal artery

US guided chest tubes require 3 pt. confirmation to avoid abdomen

Wire

Liver

1. Visualize needle in fluid

2. Visualize wire in pleura

3. Visualize pigtail in fluid

18 yo M s/p MCA

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Posterior tube

Tube in fissure

Tube is clogged

Blind midaxillary line pigtails often often don’t go to the anterior apex

Tube Malposition: Delay in Resolution of Ptx

Spontaneous Ptx

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Avoid This:

Case courtesy of Vishal Kumar, MD… he did not do this

Paracentesis

• Complications:

– Inadvertent puncture of vessel, organ, bowel

– Infection: aseptic technique

– Post Paracentesis Circulatory Dysfunction (PCD)

Caput Medusa Abdominal wall varices

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Arterial Injury s/p Paracentesis

41 yo M w/ hypotension, 3 pressors, tachy s/p paracentesis, severe pulm HTN, codes if supine or < 45 degrees

Heme Jet

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Vs. ?

Conclusions

• Lines: – Alternative line access sites only when very

comfortable with seeing needle tip with US

– Be weary of pts with long standing indwelling catheters or pacemakers…look for chest wall vessels

• Pleural access

• Paracentesis

• Most complications are avoidable

Dynamic US method is probably safest