Ultrasound guided procedures

1. Ultrasound guided procedures Dr Qurrat-ul-Ain TMO Radiology

2. US guided procedures Aspiration Drainage Biopsy

3. US guided procedures Aspirations Cysts aspiration Paracentesis (Ascites) Thoracocentesis (Pleural effusion)

4. 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

5. Cysts aspiration Cyst aspirations are done when : Causing significant tenderness The diagnosis of a cyst remains in question following the ultrasound

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

7. 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

8. 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.

9. 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.

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

11. 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.

12. Ultrasound marking and direction of Angiocath needle

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

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

15. 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 . 

16. 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 .

17. 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.

18. 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.

19. General Anatomy Pleural Effusion

20. Thoracocentesis can be both diagnostic and therapeutic . Using ultrasound to guide this procedure can decrease the very high complication rate associated with it.  

21. Right Pleural Effusion

22. Left Pleural Effusion

23. 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.

24. Minimally invasive technique Little procedure related morbidity and equal applicability to unfit patients,

25. Indications Any abnormal fluid collection which is accessible, e.g Complicated Diverticular abscess Crohn’s disease related abscess Appendicular abscess

26. 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

27. Contraindications The only common contraindications are: Abscess is not accessible  Patient has a bleeding tendency

28. 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.

29. 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.

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

31. 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.

32. Ultrasound-guided fine-needle aspirate and biopsy technique

33. Indications Icterus /liver enzyme elevation/elevated bile acids Focal nodules or masses anywhere Renal disease sometimes (i.e. renal dysplasia, renal masses, lymphosarcoma suspects) Prostatomegaly Free abdominal fluid Cysts Lymphadenopathy

34. U/S guided FNA/biopsies generally not done on: Adrenal glands Transitional cell carcinoma suspect masses Chronic renal failure, glomerulonephritis

35. Probe orientation Reference marker corresponds to left side of screen (see Screen Orientation Probe Skin Superficial “lesion” to biopsy Deep “lesion” to biopsy

36. Rock and/or slide the probe to line up the lesion to a “reachable” position Deep lesion needs to be lined up toward the edge of the beam Superficial lesion can be toward the edge or in the center of the beam

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

38. Superficial lesion FNA

39. Superficial lesion FNA

40. Superficial lesion core biopsy

41. Superficial lesion core biopsy Take biopsy

42. Superficial lesion core biopsy

43. 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

44. 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

45. 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

46. Breast Biopsy Indications Focal mass or other lesion of unknown nature – palpable or non-palpable Architectural distortion Micro-calcifications Cyst aspiration

47. 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 .

48. 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.

49. Indications

50. 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.

51. 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.

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

53. 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.

54. 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.

55. KIDNEY BIOPSY Indications: Biopsy of a focal solid lesion /suspicious cystic lesion for diagnosis. Nonfocal biopsy to evaluate for nephropathy or renal transplant rejection

56. 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 .

57. 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.

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

59. 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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