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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 any of the products or manufacturers mentioned.
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.
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
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
Gastrointestinal Intervention
• Gastrostomy
Tube
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
Gastrointestinal Intervention
• Gastrostomy Tubes
– Small bowel disease
• Crohn's disease
• Short gut syndrome
– Gastric Decompression
• Gastroparesis
• Ileus
• Obstruction secondary to malignancy
Gastrointestinal Intervention
• Gastrojeunostomy
tube
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)
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)
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.
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.
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
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
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%,
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
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.
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.
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.
Gastrointestinal Intervention
• Gastrostomy
Tube
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.
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
Percutaneous Drainage
procedures
• Thoracentesis
• Paracentesis
• Abscess / empyema
drainage
• Hematoma drainage
• Urinary
– Nephrostomy
– Suprapubic cystostomy
• Long term malignant
effusion/ ascites
management
(Aspira/Pleurx)
• Biliary
– Transhepatic biliary
– Percutaneous
cholecystostomy
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
Percutaneous Drainage
procedures: Indications
• Biliary obstruction
with
–
–
–
–
–
Pruritus
Anorexia
Cholangitis
Sepsis
hyperbilirubinemia
• Antineoplastics
excreted by liver
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
Biliary Intervention
• Contraindication to biliary drainage
– Coagulopathy is a relative contraindication
• Risk vs benefit
Biliary Intervention
• Complications (major) 2%
–
–
–
–
–
–
Sepsis
Cholangitis
Bile leak
Hemorrhage
Pneumothorax
Hemothorax
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
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
CAT SCAN
Biliary Intervention
• CT scan
– Mass in head of pancreas
– Dilated (Courvosier) GB
– Intra & extrahepatic
biliary dilation
Biliary Intervention
• Intrahepatic biliary
dilation
Biliary Intervention
• CT Coronal reconstruction
Biliary Intervention
• Percutaneous
• Transhepatic
• Cholangiography
Biliary Intervention
• Select best duct for
drainage / geometry
Biliary Intervention
• Negotiating CBD
Biliary Intervention
• Negotiating CBD
Biliary Intervention
• Access to duodenum
Biliary Intervention
• Dilating obstructed
distal CBD
Biliary Intervention
• Dilating obstructed
distal CBD
Biliary Intervention
• Internal-External
Biliary Drain in Place
Biliary Intervention
• Biliary tree
decompressed
Biliary Intervention
• Positive CT guided
biopsy for AdenoCA
• Surgical consult X 2
• Not surgically
resectable
Biliary Intervention
• Biliary tree
decompressed
Biliary Intervention
• Duodenal patency
confirmed
Biliary Intervention
• Sheath and stent in
duodenum
Biliary Intervention
• Bare stent deployed to
maintain cystic duct
patency
Biliary Intervention
• Dilate stent
Biliary Intervention
• No contrast flows to
duodenum with sheath
injection
Biliary Intervention
• Coaxial deployment of
covered stent
Biliary Intervention
• Brisk flow into
duodenum, rapid
decompression of
biliary tree and GB
Biliary Intervention
• Access Maintained
with 10.2 Fr internalexternal biliary
drainage catheter
• Downsize catheter
then remove in 2
weeks
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
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: fever>101, pericatheter
leakage, increasing pain, increasing jaundice
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
Percutaneous Drainage
procedures: Indications
• Percutaneous
nephrostomy
– majority of the cases
relieve urinary
obstruction
• benign or malignant
nature.
– treatment of urinary
fistulas
– Urosepsis
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
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)
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
Paracentesis: Contraindications
• Uncorrected bleeding
diathesis
• Previous abdominal
surgeries with
suspected adhesions
• Severe bowel
distention
• Abdominal wall
cellulitis site puncture
Paracentesis: Complications
•
•
•
•
Pain
Infection
Bleeding
Solid / hollow visceral
puncture
Thoracentesis: Indication
• Diagnostic
– Infection
– malignacy
• Therapeutic
– SOB
– Hypoxemia
– Post thoracotomy
Thoracentesis: Contraindication
• Local skin infection
oversite thoracentesis
• Uncontrolled bleeding
or clotting abnormality
Thoracentesis: Complication
•
•
•
•
Failure to remove fluid
Hemothorax
Pulmonary hemorrhage
Pneumothorax 10%
Thoracentesis: Complication
• Chest tube placement
– Significant hemothorax
– Symptomatic
pneumothorax
– Enlarging
pneumothorax
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
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
Percutaneous Abscess Drainage
Indications
• Empyema /Lung
abscess
• Appendiceal abscess
– Localized
• Diverticular abscess
– Convert two stage
surgery to one stage
Percutaneous Abscess Drainage
Indications
•
•
•
•
Post surgical abscess
Biloma
Urinoma
TOA
Percutaneous Abscess Drainage
(Relative) Contraindications
• Pt. unstable / unable to
cooperate
• No safe access
(absolute)
• Uncontrolled
coagulopathy
Percutaneous Abscess Drainage
Complications
• Pain
• Bleeding
• Puncture of non-target
organ
• Malpositioned catheter
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 <10cc/24 hours
• Change, replace or upsize tube when
dislodged or pericather drainage.
Percutaneous Abscess Drainage
• If abscess loculated, may need to
manipulate tube to breakup adhesions vs
place additional drainage catheter(s)
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