1. Interventional Radiology Percutaneous Catheters Indications, Techniques & Management By Dr. Steve J. Lengle, MD
Disclosure:
Dr. Lengle has no financial interest in any of the products or manufacturers mentioned.

2. 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.

3. 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

4. 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

5. Gastrointestinal Intervention
Gastrostomy Tube

6. Gastrointestinal Intervention
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

7. Gastrointestinal Intervention
Gastrostomy Tubes
Small bowel disease
Crohn's disease
Short gut syndrome
Gastric Decompression
Gastroparesis
Ileus
Obstruction secondary to malignancy

8. Gastrointestinal Intervention
Gastrojeunostomy tube

9. Gastrointestinal Intervention
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)

10. Gastrointestinal Intervention
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)

11. Gastrointestinal Intervention
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.

12. Gastrointestinal Intervention
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.

13. Gastrointestinal Intervention
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

14. Gastrointestinal Intervention
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

15. Gastrointestinal Intervention
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%,

16. Gastrointestinal Intervention
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

17. Gastrointestinal Intervention
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.

18. 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 hours and require a new puncture to replace the tube.

19. Gastrointestinal Catheter/Insertion site Care
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.

20. Gastrointestinal Intervention
Gastrostomy Tube

21. Gastrointestinal Catheter/Insertion site Care
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.

22. 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

23. Percutaneous Drainage procedures
Thoracentesis
Paracentesis
Abscess / empyema drainage
Hematoma drainage
Urinary
Nephrostomy
Suprapubic cystostomy
Long term malignant effusion/ ascites management (Aspira/Pleurx)
Biliary
Transhepatic biliary
Percutaneous cholecystostomy

24. 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

25. Percutaneous Drainage procedures: Indications
Biliary obstruction with
Pruritus
Anorexia
Cholangitis
Sepsis
hyperbilirubinemia
Antineoplastics excreted by liver

26. Biliary Intervention 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

27. Biliary Intervention Contraindication to biliary drainage
Coagulopathy is a relative contraindication
Risk vs benefit

28. Biliary Intervention Complications (major) 2% Sepsis Cholangitis
Bile leak
Hemorrhage
Pneumothorax
Hemothorax

29. Biliary Intervention
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

30. Biliary Intervention
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

31. CAT SCAN

32. Biliary Intervention CT scan Mass in head of pancreas
Dilated (Courvosier) GB
Intra & extrahepatic biliary dilation

33. Biliary Intervention
Intrahepatic biliary dilation

34. Biliary Intervention
CT Coronal reconstruction

35. Biliary Intervention
Percutaneous
Transhepatic
Cholangiography

36. Biliary Intervention
Select best duct for drainage / geometry

37. Biliary Intervention
Negotiating CBD

38. Biliary Intervention
Negotiating CBD

39. Biliary Intervention
Access to duodenum

40. Biliary Intervention
Dilating obstructed distal CBD

41. Biliary Intervention
Dilating obstructed distal CBD

42. Biliary Intervention
Internal-External Biliary Drain in Place

43. Biliary Intervention
Biliary tree decompressed

44. Biliary Intervention Positive CT guided biopsy for AdenoCA
Surgical consult X 2
Not surgically resectable

45. Biliary Intervention
Biliary tree decompressed

46. Biliary Intervention
Duodenal patency confirmed

47. Biliary Intervention
Sheath and stent in duodenum

48. Biliary Intervention
Bare stent deployed to maintain cystic duct patency

49. Biliary Intervention
Dilate stent

50. Biliary Intervention
No contrast flows to duodenum with sheath injection

51. Biliary Intervention
Coaxial deployment of covered stent

52. Biliary Intervention
Brisk flow into duodenum, rapid decompression of biliary tree and GB

53. Biliary Intervention
Access Maintained with 10.2 Fr internal-external biliary drainage catheter
Downsize catheter then remove in 2 weeks

54. Biliary Intervention
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

55. Biliary Intervention 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

56. Biliary Intervention 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

57. Percutaneous Drainage procedures: Indications
Percutaneous nephrostomy
majority of the cases relieve urinary obstruction
benign or malignant nature.
treatment of urinary fistulas
Urosepsis

58. 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

59. 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)

60. 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

61. Paracentesis: Contraindications
Uncorrected bleeding diathesis
Previous abdominal surgeries with suspected adhesions
Severe bowel distention
Abdominal wall cellulitis site puncture

62. Paracentesis: Complications
Pain
Infection
Bleeding
Solid / hollow visceral puncture

63. Thoracentesis: Indication
Diagnostic
Infection
malignacy
Therapeutic
SOB
Hypoxemia
Post thoracotomy

64. Thoracentesis: Contraindication
Local skin infection oversite thoracentesis
Uncontrolled bleeding or clotting abnormality

65. Thoracentesis: Complication
Failure to remove fluid
Hemothorax
Pulmonary hemorrhage
Pneumothorax 10%

66. Thoracentesis: Complication
Chest tube placement
Significant hemothorax
Symptomatic pneumothorax
Enlarging pneumothorax

67. 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

68. 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

69. Percutaneous Abscess Drainage Indications
Empyema /Lung abscess
Appendiceal abscess
Localized
Diverticular abscess
Convert two stage surgery to one stage

70. Percutaneous Abscess Drainage Indications
Post surgical abscess
Biloma
Urinoma
TOA

71. Percutaneous Abscess Drainage (Relative) Contraindications
Pt. unstable / unable to cooperate
No safe access (absolute)
Uncontrolled coagulopathy

72. Percutaneous Abscess Drainage Complications
Pain
Bleeding
Puncture of non-target organ
Malpositioned catheter

73. 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.

74. Percutaneous Abscess Drainage
If abscess loculated, may need to manipulate tube to breakup adhesions vs place additional drainage catheter(s)

75. 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