ULTRASOUND & CT

Puncture sitesAccess:

•Meticulous guiding ultrasound exam. - Shortest skin-target distance

- Avoid blood vessels, biliary tree, bowel

- Use Doppler may be helpful

- Once access decided:

Test respiratory training (deep or shallow) with short apnea to simulate biopsy moment

Advantages of US: - Real-time visualisation of the target.

-Good visualisation of the access window.

- Real-time progression of the needle with possible modification of the trajectory.

Interventional Ultrasound

Always AvoidLarge vessels,

proximal organ vesselsUreter!GallbladderParenchymatous

organs:kidney, spleen, pancreas

AVOID IF POSSIBLEBowelLiverDistal vessels

CONDITIONS OF REALISATION

One day HospitalizationOutpqtient (if cooperative, family at home, classical technique(

FastingClinical and imaging data

- platelets >150 000 - PT >70 %s

- TCA < 2x NormalStop anticoagulant TTT 8 days before.

Sedation - anxiolytic 2 hours before No sleeping patient!!

ULTRASOUND

Cleaning of probe, keyboard and cable (protocol(.

Select probe and application depending on procedure )Try to choose sectorial view if linear probe is used(

INTERVENTIONAL PROCEDURE

Skin antispetic measures by technician according to protocol

Patient covered with sterile field

Sterile material on sterile table

Cover the US probe with sterile protection

Local Anesthesia (10 à 20 cc Lidocaïne 1%(IM or LP needle according to depth of the target

- Evaluation of the trajectory - Take care of air in the syringe!

- If liver biopsy go to capsule

Needle guide (US/TDM(anesthesia

Skin deep incision with scalpel axis //ribs (intercostal artery(

INTERVENTIONAL PROCEDUREINTERVENTIONAL PROCEDURE

GUIDANCE METHOD

Biopsy Kit :

Adaptable systeme on the probe: visualization of target and needle trajectory

“ Free-hand” Technique : Probe is positioned at the entry point with needle along axis of

US beam allowing visualisation of the whole length of the trajectory (abdominal).

Always visualize your entry path with real-time needle progression

GUIDANCE METHOD GUIDANCE METHOD

Always prefer Free-hand techniqueAlways prefer Free-hand technique possibility of orientation adjustment at last minute and angle of skin penetration. Once capsule is traversed no more adjustment possible: withdraw and redress your angle

Needle aligned in the axis of US beam to visualize its swhole length

If you loose trajectory move probe 1 or 2 degrees/ needle then scree with probe in Doppler mode to search needle

GUIDANCE METHOD GUIDANCE METHOD

Always prefer Free-hand Always prefer Free-hand techniquetechnique

Needle aligned in the axis of US beam to visualize its swhole length

If you loose trajectory move probe 1 or 2 degrees/ needle then scree with probe in Doppler mode to search needle

Interventional Ultrasound

Lateral decubitusIntercostal approach! Scalpel Orientation when doing skin incision

Needles

Many varieties

Different sizes, calibers, form, shape and nature of the procedure

• Cytology : Chiba needle, Franseen

• Histology : Bard needle

Needles

Many varieties

Interventional Ultrasound

If solid mass : biopsy 18/16 G ‘True cut’If cystic mass : initial Fine Needle Aspiration

(FNA)-Don’t empty-wall biopsyIf possible do microbiopsy (histology) of the

wall

‘Co-axial’ Technique

2 types : co-axial - tandem

Coaxial : 1 large bore needle (19G) in contact with the lesion ; multiple samples taken with smaller and longer needle inserted

within it (20G( Advantage : One puncture with multiple samples (<hemorragic

risk but only one direction(

Tandem : 1 needle in the lesion ; biopsy needle parallel

Advantage : trajectory already done and multiple directions of biopsy

Interventional Ultrasound

Automatic needle: one action movementProgression with needle tip visualisation during

apneaAdjust needle length

If gun is used consider length of specimen (wall/necrosis(

3 Specimens Change needle (FNA / microbiopsy) depending on

tissue obtained•Biopsy of normal liver also

Liver

Increased hemorragic risk if hemangioma punctureFill the needle track with Gelfoam

Interventional Ultrasound

Possible puncture of distal portal or hepatic branches

Biopsy subcapsular lesion by penetration through normal liver.

Use respiration to move the diaphragm and keep away the pleuram recess from the needle to get below it

Coaxial Technique

GUERIDON PRELEVEMENT

Sterile table1 gauze

1 ampoule of normal saline (moisten biopsy(1 bottle of Formol or wet gauze

If drainage : tubes of bacteriology for culture & sensitivity

DEALING WITH SPECIMENS

BIOPSIES LIVER KIDNEY LYMPH NODES PANCREAS OR ABDOMINAL MASS:

1st time : place on gauze then wet with normal saline (during puncture(

2nd time : Place in formol.

FNA OR COLLECTION DRAINAGE :

Aspiration with syringe then put aspirate in sterile tube for bacteriological studies.

COMPLICATIONS

Complications are rare (0,008% à 0,03 %)

-Vasovagal attack

Severe complications

- hemorrhage, arterio-veinous fistula, hematoma andpneumoperitoneum (liver)

- Acute pancreatitis if normal pancreatic tissue

- Metastatic seeding of the needle track.