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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
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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 occlusion
– Very common in pts with chronic catheter pts and dialysis fistulas
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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%
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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
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R Vertebral artery
Cordis tip
R CCA
These get filled with thrombus
54 yo F s/p L chest wall resection
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Pseudoaneurysm and Brachial a. Embolus
Subclavian Covered Stent
s/p attempted R IJ placement
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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 often 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