Invasive Radiology

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Invasive Radiology

• Dr. Fern Karlicki
• (the one who LIKES to put needles in people at
  St. Boniface Hospital)

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Invasive Radiology

• After this workshop, participants should be
  familiar with
• Common imaging guided procedures
• Patient preparation prior to a procedure
• Post procedure complications

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Invasive Radiology

• 10 of Rads do procedures
• 96 of procedures are done with US guidance
• US is cheap, portable, quick, involves no
  radiation, and gives superior diagnostic yields
  (87 vs 77 ) compared to CT
• CT used when US cant see lesion
• Technical, air, obesity, bone

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Common Imaging Guided Procedures

• Solid organ biopsy - random core of liver and
  renal most common
• Biopsy of masses fine needle or core
• Breast , liver , thyroid , kidney , pancreas , GB
  , nodes , ovary , bowel , MSK , etc

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Common Imaging- Guided Procedures

• Thoracentesis / chest tube insertion
• Abscess / fluid collection - asp or drain
• Ascites asp or drain
• GB/biliary drain
• Nephrostomy tubes
• Cyst asp

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Imaging guided Procedures

• General preparation
• Informed consent
• Local anesthetic
• Aseptic technique
• Sedation rarely needed (endovaginal drainages
  are the exception - ALWAYS done with conscious
  sedation
• Safest pathway - not always the shortest

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Procedures that require little or NO Special Prep

• Breast biopsies
• Superficial biopsies and aspirations e.g. ant
  abdominal wall or extremity mass / fluid
  collection
• Paracentesis
• Thyroid biopsies - D/C anticoagulants /- ASA
  / NSAIDS ? D/C Plavix if safe

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Preparing your Patient for all Deep Organ
Procedures

• Fasting 6 hours
• Stop ASA / NSAIDS 1 week prior (some say only for
  renal / spleen bx)
• Stop Plavix 3-5 days prior - ONLY IF SAFE re
  coronary artery stent
• Stop warfarin 3-5 days prior (INR lt 1.5)
• Stop heparin 6 hours prior
• Stop LMWH 12 hours prior

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Parameters for Deep Organ Biopsy

• INR lt 1.5 2
• Platelets gt 50,000 - how they function is
  important
• Hb - we just need a value
• Bleeding time on dialysis patients
• PTT lt 40

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Fine needle or Core??

• Core biopsies with automated device
• Minimum 1.5 cm throw - 14-22G
• More info than fine needle
• More bleeding risk
• More risk of non-target organ injury
• Fine needle ( /- aspiration)
• Thyroid , liver , pancreas , lymph nodes
• Good for small lesions in tight spaces

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Drainage Catheters

• 8.5 french or larger
• Self locking pigtail
• Secured at the skin
• They still fall out
• Uncomfortable
• Aspiration may be preferable

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General post - procedure Complications

• Infection rare
• Vasovagal
• Pain
• Bleeding
• Non target organ injury

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Post Procedure Monitoring

• Only needed for deep organ biopsy
• Bed rest and vital signs 2-5 hours after
• Observe total of 3-6 hours

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• THERE IS AN
• EPIDEMIC
• OF THYROID NODULES
• REQUIRING
• BIOPSY!!!!!!

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Thyroid Nodules

• In the past, only palpable thyroid nodules would
  undergo biopsy
• Now, many small non-palpable nodules are
  discovered on CT or US done for other reasons

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Thyroid Nodules

• 50 of people have thyroid nodules
• The vast majority (90) are benign
• Tiny, clinically insignificant cancers can be
  found at autopsy in up to 50 of people
• The incidence of thyroid cancer has doubled in
  the last 20 years yet mortality is unchanged

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Thyroid Nodules

• WHO to biopsy?
• Head and neck radiation
• Family history
• lt30 yo
• gt60 yo
• Male
• Firm, fixed, growing
• Lymphadenopathy

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Thyroid Nodules

• WHAT to Biopsy?
• gt 1 cm solid microcalcifications
• gt 1.5 cm solid
• gt 2 cm complex cystic
• The largest is NOT ALWAYS the cancer - 30 of
  cancers will be a non dominant nodule
• In MNG need to pick the scariest

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Thyroid Biopsy

• Local anesthesia
• 25 g - capillary - multiple passes
• Target solid vascular portion
• 70 satisfactory
• 20 inconclusive
• 5-10 unsatisfactory

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Thyroid Biopsy Complications

• Biggest one is not getting an answer!!!
• Follow??
• Re biopsy??
• Core biopsy more bleeding
• Bleeding
• Airway compromise rare
• Non-target organ injury

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Core Renal Biopsy in Renal Failure

• Riskiest biopsy we do
• 14-16 g
• Renal blood flow
• Vasculitis
• High BP
• Prolonged bleeding time
• Chronic component with fibrosis

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Core Renal Biopsy in Renal Failure

• We need these patients BUFFED
• Need to D/C EVERYTHING that can thin the blood
• Nephrology consult to determine need for biopsy

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Core Renal Biopsy Complications

• 90 have a perinephric hematoma
• Average hemoglobin drop is 2 gms
• 20 have transient gross hematuria
• 15 develop AVF that leads to ongoing hematuria
  but few need embolization

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Renal Mass Biopsy

• Epidemic of incidental renal mass detection
• More than 50 of these incidentalomas are benign
• Biopsy is evolving as a way to avoid unnecessary
  nephrectomy

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Renal Mass Biopsy

• Urologist consult
• Most useful for
• Suspected lymphoma
• RCC vs mets
• Confirm unresectable RCC
• Oncocytosis
• lt 3 cm masses
• Complex cystic masses
• Infection

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Renal Mass Biopsy Technique

• 18 g co-axial
• 1.3 bleeding complications e.g. hematomas
  needing transfusion AVF / pseudoaneurysm
• No tumor seeding
• 95 diagnostic

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Core Breast Biopsy

• 14 g
• 2-6 passes
• 95 accurate
• Fibrous and heterogenous lesions may need
  re-biopsy, follow-up or sx
• Specific complication of lung perforation

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Liver Biopsy

• Random core 18 g for HC/HB/HIV autoimmune
  hepatitis etc
• Targeted lesion - fine needle or core
• The larger the needle the higher risk of bleeding
  especially for sub-capsular lesions or in the
  face of cirrhosis

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My Motto

• You can stick a 22 g needle just about anywhere
  with impunity
• A biopsy is often the shortest, quickest,
  cheapest and most efficient way to an answer when
  imaging is unlikely to be 100 definitive

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