ULTRASOUND GUIDED PROCEDURES

Dr Qurrat-ul-AinTMO Radiology

US guided procedures

Aspiration

Drainage

Biopsy

US guided procedures

Aspirations

Cysts aspiration

Paracentesis (Ascites)

Thoracocentesis (Pleural effusion)

Cysts aspiration: Cysts are very common. Usually be diagnosed accurately with

ultrasound. In most women, they do not usually

require any intervention or follow-up.

US guided procedures

Cysts aspiration

Cyst aspirations are done when :

• Causing significant tenderness • The diagnosis of a cyst remains in question

following the ultrasound

Technique

POSITION

The patient lie on her back or slightly turned to one side with the arm placed comfortably under the head.

The skin is cleaned , numbed with topical anesthesia. Using ultrasound guidance, a small needle is advanced into the cyst and suction is applied to draw the fluid out, causing the lump to collapse.

Technique

The lump (arrow) in this patient’s right breast was thought to be a cyst, but some features are not characteristic and aspiration was necessary.

Using ultrasound guidance, a fine needle (white line) is placed so that its tip (double arrow) is in the center of the lump (single arrow). Aspiration is applied by using a syringe attached to the needle. If this is a cyst, fluid is drawn into the syringe as the lesion collapses.

After the aspiration, the needle (white line) and its tip (double arrow) are seen, but the lump is gone.

Ultrasound Guided Paracentesis

If is very helpful to get an ultrasound scan of the ascites before the procedure.

The radiologist will mark the spot for paracentesis. Two things are important:

What is the distance from the skin to the fluid? Usually 1 cm.

What is distance to the midpoint of the collection? Usually 3 cm.

Ultrasound marking and direction of Angiocath needle

Here we clearly see free fluid in Morrison's pouch that extends superiorly around the liver

See the needle entering the peritoneal cavity obliquely from just beneath the indicator marker.  

Thoracocentesis (Pleural effusion)

Pleural effusion is an abnormal collection

of fluid in the pleural space.  Removal of

this fluid by needle aspiration is called a

thoracoentesis. 

Ultrasound Guided Technique

Patient should be sitting or in the lateral decubitus position with pleural effusion side up.

The marker on the probe should be pointed towards the head. Be sure that the transducer is perpendicular to the chest .

The diaphragm and liver or spleen should be identified first.

The probe can then be moved towards the head and from side to side to locate the largest pocket of fluid between the ribs. Once this is located a mark is made with indelible ink just above the lower rib.

The distance from the transducer to the

pleural fluid should also be noted.

The probe is then rotated 180 degrees to

visualize the pleural fluid between the ribs

to ensure that there is only fluid visualized

ie. no lung, diaphragm, or liver or spleen.

General Anatomy Pleural Effusion

Thoracocentesis can be both diagnostic and

therapeutic . Using ultrasound to guide this

procedure can decrease the very high

complication rate associated with it.  

Right Pleural Effusion

Left Pleural Effusion

U/S guided p/c Abscess Drainage

Procedure allow collections which would otherwise require open surgery to be drained via a skin incision only a few mm in size.

Minimally invasive technique

Little procedure related morbidity and

equal applicability to unfit patients,

Indications

Any abnormal fluid collection which is accessible, e.g

Complicated Diverticular abscess

Crohn’s disease related abscess

Appendicular abscess

Localized abscess related to ovary (tubo-ovarian)

Abscess collection after surgery

Hepatic abscess (amebic or post-op)

Renal abscess or retro-peritoneal abscess. 

Splenic abscess

Contraindications

The only common contraindications are:

Abscess is not accessible 

Patient has a bleeding tendency

Technique

Abscess is first delineated &a safe route from skin to the abscess cavity is identified by ultrasound.

Prior to the catheter introduction, a diagnostic needle aspiration may also be done.

The catheter is introduced into the abscess cavity, either directly using a trocar catheter (as used for chest intubation (or by modified Seldinger’s technique using a guide-wire.

Maneuvering of the trocar or guide-wire within the abdominal cavity should be done strictly under ultrasound surveillance

Once in position, the catheter is secured

and attached to a drainage bag.

Drainage is recorded daily ,response to the

treatment is assessed by clinical

parameters & u/s.

ULTRASOUND-GUIDEDFINE-NEEDLE ASPIRATE AND BIOPSY TECHNIQUE

IndicationsIcterus/liver enzyme elevation/elevated bile acidsFocal nodules or masses anywhereRenal disease sometimes (i.e. renal dysplasia, renal masses, lymphosarcoma suspects)ProstatomegalyFree abdominal fluidCysts Lymphadenopathy

U/S guided FNA/biopsies generally not done on:

Adrenal glands Transitional cell carcinoma suspect

masses Chronic renal failure, glomerulonephritis

Probe orientationReference

marker correspondsto left side of screen

(see Screen Orientation Probe

Skin

Superficial “lesion” to biopsy

Deep “lesion” to biopsy

Rock and/or slide the probe to line up the lesion

to a “reachable” position

Deep lesion needsto be lined up

toward the edge of the beam

Superficial lesioncan be toward the edge

or in the center of the beam

Angle to use for a superficial lesion: Aim needle more perpendicular to beam

Superficial lesion FNA

Superficial lesion FNA

Superficial lesion core biopsy

Superficial lesion core biopsy

Take biopsy

Superficial lesion core biopsy

Percutaneous needle biopsy of the breast provides reliable diagnosis of both benign and malignant disease and is a proven alternative to open surgical biopsy

Breast Biopsy

Ultrasound guidance is an accurate and reliable biopsy guidance technique and is the method of choice and suitable for all breast lesions visible on ultrasound

Breast Biopsy

CNB & FNAB are effective methods for the diagnosis of most breast lesions

Although CNB has higher sensitivity &

positive predictive value for abnormalities

like micro-calcifications & distortions of

architecture.

Breast Biopsy

Breast Biopsy Indications

Focal mass or other lesion of unknown nature – palpable or non-palpable

Architectural distortion Micro-calcifications Cyst aspiration

U/S GUIDED BREAST BIOPSY PROCEDURE: The long axis of the needle, should be

visible along the long axis of the transducer. Occasionally, during an FNA biopsy or cyst

aspiration, the transducer can be rotated 90 degrees to visualize the echogenic dot of the needle within the lesion.

US Liver Biopsy

Liver biopsies are performed for both

focal and nonfocal lesions.

The primary indication for parenchymal

liver biopsy is for the diagnosis of hepatic

disease.

Indications

U/S GUIDED LIVER BIOPSY When imaging guidance is employed, it

can take one of two forms: US-guided "marking" in which a mark is

made upon the skin during US examination for a biopsy to be performed later without imaging guidance or real-time US guidance.

The patient position

The patient is positioned supine, with the

hands comfortably resting behind the

head

A preliminary US scan is performed to

identify the target and mark the skin.

The preliminary scan also ensures that no major vessels, dilated biliary channels or gall bladder are in the path of the biopsy needle.

Before the procedure is started, breathing

instructions are practiced with the patient.

performed with the breath held in expiration.

This minimize risk of injury to the pleura or lung.

The skin site is prepped and draped to

ensure asepsis The local area is

anesthetized with a local anesthetic.

The cutting needle is then fired with US

documentation of the site.

KIDNEY BIOPSY

Indications:

Biopsy of a focal solid lesion /suspicious

cystic lesion for diagnosis.

Nonfocal biopsy to evaluate for

nephropathy or renal transplant rejection

US has the advantages of real-time needle

placement

No radiation & is therefore well suited for most

nonfocal renal biopsies in thin pts and in

biopsies of some focal solid masses or cystic

masses .

Procedure Technique

The patient is placed in the prone position and the biopsy is typically taken from the lower pole of the kidney if there are no specific locations of interest.

The biopsy needle is guided using ultrasound to ensure visualization of the needle as it pierces the kidney parenchyma.

Care is taken not to enter the collecting system (as it would result in haematuria) or to go near the renal hilum (to prevent injury to the vessels).

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