Disclosures: Image Guided Procedures Pearls, Pitfalls, and - - PDF document

5/9/2015 1

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

5/9/2015 4 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

• cclusion

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

5/9/2015 6

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%

5/9/2015 7

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

5/9/2015 8

R Vertebral artery Cordis tip R CCA

These get filled with thrombus

54 yo F s/p L chest wall resection

5/9/2015 9 Pseudoaneurysm and Brachial a. Embolus

Subclavian Covered Stent s/p attempted R IJ placement

5/9/2015 10 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

• ften 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