Interventional Radiology Percutaneous Catheters Indications, Techniques & Management By Dr. Steve J....

Interventional Radiology Percutaneous CathetersIndications, 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


• Gastrostomy Tube


• 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


• Gastrostomy Tubes– Small bowel disease

• Crohn's disease

• Short gut syndrome

– Gastric Decompression• Gastroparesis

• Ileus

• Obstruction secondary to malignancy


• Gastrojeunostomy tube


• 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)


• 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)


• 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.


• 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.


• 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


• 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


• 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%,


– 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


• 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.


• 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.


• Gastrostomy Tube


• 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

• Long term malignant effusion/ ascites management (Aspira/Pleurx)

• Biliary– Transhepatic biliary

– Percutaneous cholecystostomy

• Thoracentesis• Paracentesis• Abscess / empyema

drainage• Hematoma drainage• Urinary

– Nephrostomy

– Suprapubic cystostomy

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


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


• Contraindication to biliary drainage– Coagulopathy is a relative contraindication

• Risk vs benefit


• Complications (major) 2%– Sepsis– Cholangitis– Bile leak– Hemorrhage– Pneumothorax– Hemothorax


• 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


• 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


• CT scan – Mass in head of pancreas

– Dilated (Courvosier) GB

– Intra & extrahepatic biliary dilation


• Intrahepatic biliary dilation


• CT Coronal reconstruction


• Percutaneous• Transhepatic• Cholangiography


• Select best duct for drainage / geometry


• Negotiating CBD


• Access to duodenum


• Dilating obstructed distal CBD


• Internal-External Biliary Drain in Place


• Biliary tree decompressed


• Positive CT guided biopsy for AdenoCA

• Surgical consult X 2• Not surgically

resectable


• Biliary tree decompressed


• Duodenal patency confirmed


• Sheath and stent in duodenum


• Bare stent deployed to maintain cystic duct patency


• Dilate stent


• No contrast flows to duodenum with sheath injection


• Coaxial deployment of covered stent


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


• Access Maintained with 10.2 Fr internal-external biliary drainage catheter

• Downsize catheter then remove in 2 weeks


• 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


• 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


• 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 DrainageComplications

• 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

Interventional Radiology Percutaneous Catheters Indications, Techniques & Management By Dr. Steve J....

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Transcript of Interventional Radiology Percutaneous Catheters Indications, Techniques & Management By Dr. Steve J....