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Ba sic ir interventions

This document provides guidance on basic interventional radiology (IR) procedures including venous lines, feeding tubes, and biliary drainage. It describes different types of venous lines including PICCs, ports, and Hickman/Permacath lines. Details are given on indications, contraindications, pre-procedure care, technical steps, post-procedure care, and potential complications. Guidance is also provided on placing feeding tubes including gastrostomy and gastrojejunostomy tubes using push or pull techniques. Technical tips, outcomes, and controversies are discussed for each procedure type.

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BASIC IR INTERVENTIONS A layfellow’s guide
BASIC IR INTERVENTIONS Venous lines Feeding tubes Biliary drainage AV graft and fistula declots IVC filters
VENOUS LINES
WHAT LINE, WHEN? PICC Po r t - a - C a t h Hickman 4F or 5F, single or dual-lumen 8F, single lumen 9F, single or dual-lumen Dwell time: Days to months Dwell time: Months to years Dwell time: Months to years Chemotherapy, antibiotics, TPN Intermittent access Frequent or continuous access Chemotherapy, rarely antibiotics Continuous infusions (Pulm or TPN HTN, dobutamine, etc) Quinton/Niagara Pe r m a c a t h 13.5F, dual-lumen 14F, dual-lumen Dwell time: <2 weeks Dwell time: Months to years Short-term hemodialysis or Hemodialysis or expected repeat plasmapheresis plasmapheresis Awaiting AV graft/fistula, or cannot Rapid infusion have AV graft/fistula
INDICATIONS/CONTRAINDICATIONS Indications: Contraindications (all are relative): Short-term venous access Quinton: None (Quinton, PICC) PICC: None Long-term venous access Port: Active infection, INR (Hickman, Permacath, Port) >1.5, platelets <50, neutropenia Permacath: Sepsis or bacteremia, INR > 2, platelets <50 Hickman: Sepsis or bacteremia, INR >2, platelets <50
PRE-PROCEDURE Antibiotics Required for Port, optional for Permacath and Hickman, unnecessary for PICC and Quinton Ancef 1 gram IV Alternative for PCN allergy: Clindamycin 600 mg IV or Vancomycin 1 gram IV Review any prior venograms and cross-sectional imaging
PROCEDURE (QUINTON) 1. Right IJ approach favored (subclavian or femoral if needed) 2. Ultrasound site prior to prepping to confirm vein patency 3. Prep and administer 10 cc lidocaine in skin and soft tissues 4. 21 gauge needle with slip-tip syringe, access vein under ultrasound, aspirate to confirm 5. Pass microwire into RA and place micropuncture catheter 6. Upsize to 035 Amplatz wire, direct into IVC 7. Dilate and place Quinton 8. Flush/aspirate and lock with heparin (1000 units/cc)
PROCEDURE (PERMACATH/HICKMAN) 1. Initial steps same as Quinton; ensure that IJ access is as low as possible 2. Before removing micropuncture wire, place at desired site of catheter tip (cavoatrial junction to mid-RA) and measure length 3. Once 035 wire in place (in IVC), anesthetize exit site and tract 3-4 finger breadths below clavicle 4. Single blade puncture, tunnel catheter to neck puncture site and pass all the way through up to hub 5. Serial dilation and place peel-away sheath (watch with fluoro) 6. Remove inner dilator and pass catheter into SVC/RA 7. Flush/aspirate and lock with heparin (1000 units/cc for Permacath, 100 units/cc for Hickman) 8. Suture with 2-0 silk or Prolene
PROCEDURE (PORTACATH) 1. Wide prep, antibiotics and full surgical scrub 2. Initial steps same as Quinton; ensure that IJ access is as low as possible 3. Once 035 wire placed, anesthetize port incision site and pocket (about 4 finger breadths below clavicle) 4. 2 cm transverse incision with 15 blade 5. Open pocket above incision with forceps and finger; should be snug to prevent port flipping 6. Pre-assemble and flush port, attach catheter and tunneler 7. Tunnel catheter through tract and out of neck puncture site and gently pull port into pocket 8. Place catheter over chest and trim to desired length; use micropuncture wire to confirm 9. Serially dilate and place peel-away sheath 10. Pass catheter through peel-away sheath and confirm adequate position with fluoro 11. Peel away sheath and massage catheter smoothly into tract 12. Flush and aspirate port and lock with heparin (100 units/cc) 13. Place 2-3 deep 3-0 Vicryl sutures to approximate incision 14. Place 4-5 subcuticular interrupted 4-0 Vicryl sutures to complete closure 15. Dermabond and place Telfa dressings 16. Consider leaving port accessed (if use within 24-48 hours)
TECHNICAL TIPS MR venography can be very useful in patients with multiple venous occlusions With IJ access, keep position of carotid in mind, and direct needle away from it when possible Low IJ access can be aided by accessing just above clavicle from side of ultrasound probe Always place wire down IVC. If difficult, use deep inspiration, or use 5F Kumpe catheter and/or angled glidewire to cannulate When right IJ not available, sequential order of veins to be used: Left IJ, right or left EJ, right or left subclavian, right or left femoral, jugular collateral, transhepatic, transcaval. Usually venous recanalization should be attempted prior to resorting to transhepatic or transcaval lines. Avoid subclavian access on the side of an existing or planned dialysis fistula Use meticulous sterile technique!
POST-PROCEDURE CARE Keep site clean and dry; no swimming or baths For showering, site should be covered (e.g. Tegaderm) and kept out of direct stream of water Port follow up in clinic in 7 days (call 310-481-7545 for appt) Sutures for Hickman and Permacath can be removed at 2-3 weeks
COMPLICATIONS Carotid or subclavian artery puncture With needle: Remove needle, hold firm but non-occlusive pressure for 10-15 minutes With dilator/catheter: Surgical consult, can consider closure device and/or balloon tamponade Air embolism Usually occurs when patient takes a forced inspiration at the time of dilator removal from the peel-away sheath; a sucking sound is often heard Air usually passes into outflow tract of right ventricle (may be visible on fluoro); can obstruct pulmonary trunk Leave patient in supine position until air is absorbed (may take up to 20 minutes) Continuous vital sign monitoring; administer oxygen by face mask or 100% non -rebreather If patient not doing well, turn patient on his/her left side and place head down if possible; catheter aspiration Infection Exit site or tunnel infection: local erythema, tenderness, induration or drainage; no systemic symptoms; usually treatable with local wound care and antibiotics; culture exudate if present Catheter-related bacteremia: fever or sepsis; catheter should be exchanged or removed and IV antibiotics required Catheter occlusion Fibrin sheath: forms within a week and may cause catheter dysfunction Can flush but cannot aspirate; venogram to diagnose Attempt tPA first; if fails, consider catheter replacement with or without sheath disruption, stripping
OUTCOMES Technical success rate nears 100% Catheter infection rates are comparable for lines placed in IR suite and OR 5/1000 catheter-days for Quinton 1-2/1000 catheter-days for PICC 1.3/1000 catheter-days for Permacath/Hickman 0-1/1000 catheter-days for Portacath Asymptomatic catheter-related venous thrombosis occurs in 28-54% Symptomatic catheter-related venous thrombosis occurs in 2.8-16%
CONTROVERSIES Hickman vs. Groshong Access site Hickman has simple cut tip; Subclavian vein has higher chance of Groshong has valved tip pinch-off syndrome and higher Valved tip prevents need for heparin likelihood of symptomatic occlusion lock of line Femoral vein has higher infection But, no improvement in patency risk Groshong more difficult to place Internal jugular access is favored whenever possible
TROUBLESHOOTING Catheter occlusion C e n t r a l ve n o u s o c c l u s i o n 1. X-ray to document line position 1. Thrombosis risk: 45% if 2. If position OK, give 2 mg tPA catheter tip in innominate vein; into line and let dwell 2-3 hours 19% if tip in upper SVC; <5% if tip in lower SVC or upper 3. If fails, infuse 1 mg tPA/hour right atrium over 3-4 hours 2. Treat with anticoagulation 4. Catheter stripping from femoral vein for ports and Hickmans 3. If fails, remove device and continue anticoagulation 5. Catheter exchange for Permacaths and PICCs 4. If this fails, can consider lysis
ENTERIC FEEDING TUBES
INDICATIONS/CONTRAINDICATIONS Indications: Contraindications: Long-term nutritional support Colonic interposition Long-term SBO decompression Portal HTN Moderate or large ascites Previous gastric surgery (relative) INR >1.5 Platelets <75K
PRE-PROCEDURE NPO 8 hours Consider 200 cc of dilute barium suspension given the night prior Consider antibiotics (usually unnecessary) Consider glucagon 1 mg IV at start of procedure
PROCEDURE (PUSH TYPE) 1. Ultrasound and mark liver edge 2. Place small bore NG tube 3. Insufflate stomach 4. Fluoro to confirm safe window – use lateral if necessary 5. 1% lidocaine, all the way into stomach along expected path (slightly rightward) 6. 3 T-fasteners; watch under fluoro; inject to confirm position 7. Puncture stomach and place 035 Amplatz wire 8. Pre-load 8 mm x 4 cm balloon into 18F G tube 9. Pass balloon/tube over wire, place balloon into tract and fully inflate 10. Advance balloon and tube into stomach as balloon deflates 11. Inflate G tube balloon with 10 cc sterile H20 and secure disk
PROCEDURE (PULL TYPE) 1. Prophylactic antibiotics (Ancef 1 gram IV) 2. Ultrasound and mark liver edge 3. Place small bore NG tube 4. Insufflate stomach 5. Fluoro to confirm safe window – use lateral if necessary 6. 1% lidocaine, all the way into stomach along expected path (toward fundus) 7. Puncture stomach and place 6F sheath 8. Pass wire down esophagus and snare from stomach using goose-neck snare 9. Secure tube onto wire from oral end and pull wire and tube through mouth and down through stomach and abdominal wall 10. Trim tube and place hub; secure outer bumper against abdominal wall
PROCEDURE (GASTROJEJUNOSTOMY) 1. Usually used for patients with gastric reflux, aspiration, or poor gastric emptying 2. Initial steps same as push-type gastrostomy 3. Once T-fasteners placed, puncture into stomach and place 6F sheath 4. Use Kumpe catheter and stiff angled glide wire to cannulate pylorus and through duodenum into proximal jejunum 5. Serial dilators with peel-away sheath (22F for 18F GJ tube) or balloon dilation of tract 6. Pass GJ tube over stiff angled glidewire into jejunum; monitor under fluoro 7. OK to use jejunal port immediately 8. Compared to G tubes, GJ tubes: Technically more difficult Clog more frequently Require more expensive elemental diet Require slow infusion to prevent dumping
TECHNICAL TIPS Do not underestimate G tubes! Review CT scans prior to procedure Maintain stomach inflation for all steps Localize colon and stomach using AP and lateral fluoro Small bowel is only rarely anterior to stomach In difficult cases, use DynaCT Antrum or mid-body are best targets (careful of inferior epigastric artery) Avoid greater and lesser curvatures (gastric/gastroepiploic arteries) Watch all needle advancements into stomach under fluoro (look for tenting at needle tip; use logic and avoid needle over-advancement) If tube does not pass easily, re-inflate balloon, re-inflate stomach, and re-try (don’t force the tube in, may push stomach away instead)
POST-PROCEDURE CARE Stomach rest for 24 hours (NPO, do not use tube except for decompression) T-fastener removal in 1 week Routine flushing of tube before and after each use Liquefy anything placed through tube (pills should be finely crushed and liquefied)
COMPLICATIONS Gastrointestinal perforation (especially transverse colon) If just needle: OK to withdraw, re-direct, and continue procedure (give antibiotics) If tract dilated or G tube placed: Consult surgery (do not remove tube) Peritoneal positioning leading to peritonitis Be critical of final G tube injection to confirm intragastric position If access to stomach lost during tract dilation, OK to re-puncture and continue; consider antibiotics and longer stomach rest before feeding Wound infection Local skin care; consider Keflex 500 mg PO BID x 7-10 days Consider tube exchange or removal; Consider CT scan to evaluate for abscess Aspiration Consider conversion to GJ tube Catheter falls out Have ER place something in tract (Foley catheter) Can usually re-cannulate established tract within 24 hours of tube dislodgement
OUTCOMES Technical success rate ~98% Lower morbidity and mortality rate than surgical tube placement Equivalent morbidity and mortality to endoscopic tube placement 2% major complication rate 6% minor complication rate
CONTROVERSIES Gastropexy? P u l l ve r s u s P u s h ? Randomized study of 90 patients (48 Pull-type advantages: No gastropexy, 42 not) gastropexy, no balloon which can G tube successful in 100% of pexy rupture, mushroom retention device patients very effective G tube failed (placed into peritoneal Pull-type disadvantages: Sometimes cavity) in 10% of non-pexy patients hard to snare wire in Excoriation or pain seen around pexy stomach, chance of abdominal wall site in 10% of pexy patients infection, may be harder to convert Increased number of punctures can to GJ increase bleeding risk
TROUBLESHOOTING Tu b e o c c l u s i o n Tu b e l e a k a g e 1. Flush with water or saline 1. Secure disc so that balloon is well- 2. Flush with Coca-Cola apposed to inner margin of stomach 3. Pass a wire under fluoro 2. Ensure that balloon is not obstructing gastric outlet 4. Replace tube 3. Antacids 4. Local antibiotic ointment 5. Paracentesis (if ascites) 6. Upsize tube 7. Use suture to tighten tract
BILIARY DRAINAGE
INDICATIONS/CONTRAINDICATIONS Indications: Contraindications (all are relative): Relieve biliary obstruction when Marked ascites ERCP has failed or is not indicated Multiple obstructed, isolated biliary Manage cholangitis segments (sclerosing Diagnosis cholangitis, mets) INR >1.5 Platelets <75
PRE-PROCEDURE Antibiotics: Zosyn 3.375 grams IV or Ceftriaxone 1 gram IV Review cross sectional imaging Choose desired approach: Right side: Generally easier to perform under fluoro, less radiation to hands Left side: Generally easier to perform under ultrasound
PROCEDURE 1. Wide prep and insonate liver with ultrasound 2. Advance 21 or 22 gauge Chiba under US and/or fluoro 3. Attach contrast syringe with extension tubing, gentle injection as needle is withdrawn 4. When duct entered, opacify biliary tree with contrast and decide if suitable; if not, repuncture suitable duct 5. Once accessed, pass 018 wire, upsize to Accustick catheter 6. Use 4F glide catheter and 035 angled glide wire to navigate through occlusion (if not infected) 7. Place stiff wire, consider cholangioplasty (4-8 mm, 2 min inflation, high pressure) 8. Dilate tract and place biliary drain (usually 8-10F)
TECHNICAL TIPS This procedure is painful! Liberal use of narcotics/sedation Do not use very central bile duct access for tube placement, due to increased chance of vascular injury Left access: 1. Use ultrasound liberally 2. Segment 3 is most accessible, but usually posterior to adjacent portal vein 3. Angle rightward with access needle to produce favorable wire trajectory Right access: 1. Be careful of pleural reflection; access below 10 th rib laterally 2. Advance along course of posterior rib toward hilum, parallel to floor 3. Change angulation if no bile duct accessed (more posterior and cranial)
POST-PROCEDURE CARE Keep site clean and dry; no swimming or baths For showering, site should be covered (e.g. Tegaderm) and kept out of direct stream of water Flushing tube is OK but optional; do not aspirate Benign strictures short course: 1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h 2. Return in 6 weeks, re-inject; if patent, place external drain, cap at 24h 3. If no symptoms develop, remove tube 1-2 weeks later Benign strictures long course: 1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h 2. At 6 weeks, repeat cholangioplasty, upsize to 12F, cap at 24h 3. At 12 weeks, repeat cholangioplasty, upsize to 14F, cap at 24h 4. At 18 weeks, re-assess, if patent, place external drain, cap at 24h 5. If no symptoms develop, remove tube 1-2 weeks later
AV GRAFT AND FISTULA DECLOTS
INDICATIONS/CONTRAINDICATIONS Indications: Contraindications: Elevated venous pressures Infected vascular access Decreased flow (<600 mL/min) Long-segment (>7 cm) Prolonged bleeding after needle stenosis/occlusion – consider removal surgery Arm swelling Severe hyperkalemia – place Quinton instead Thrombosis Nonmaturing fistula (by 3 months) Relative: INR >2.0, platelets <25K
PRE-PROCEDURE Check history; if >2 interventions in last month, surgery may be indicated Check labs (especially potassium) Palpate fistula and outline anatomy; ensure absence of infection Palpate and document pulses, capillary refill, warmth in affected limb Ultrasound can help delineate anatomy as well as sites of stenosis and best site for access
PROCEDURE (FISTULAGRAM) 1. Access fistula near anastomosis but pointing toward venous outflow 2. Place micropuncture catheter 3. If flow is present and no clot, perform outflow and central venography followed by blow-back angiogram of the anastomosis 4. Consider oblique views to help define anatomy 5. Interventions as needed
PROCEDURE (CLOTTED AV GRAFT) 1. Access graft near arterial anastomosis, toward venous outflow; place 6F short sheath 2. 5F Kumpe catheter and glidewire to access axillary vein 3. Central venography 4. Pull-back puffs of contrast until reach area of thrombosis 5. Lace back to sheath with 2 mg of tPA in 10 cc (use most but not all); give 3000-5000 units heparin IV 6. Access graft near venous anastomosis, toward artery; place 6F short sheath; administer remainder of tPA 7. 6 or 7 mm x 4 cm PTA of all venous limb and graft back to the sheath; 90 second inflations for areas of stenosis 8. Pass 4 or 5 mm x 2 cm PTA (or Fogarty balloon) across arterial anastomosis; inflate to 1-2 atm, gently pull across anastomosis and watch for waist; repeat and angioplasty waist if present 9. Kumpe catheter across arterial anastomosis and perform graftogram 10. Repeat venous and arterial PTA as needed, +/- mechanical 11. X-stitch to close puncture sites (3-0 Vicryl)
TECHNICAL TIPS Access sheaths should not cross (reduces flow) May need Conquest balloon or cutting balloon for resistant venous stenoses Don’t inject clotted graft; always puff contrast to ensure forward flow prior to runs Careful with blow-back angiography, make sure there is no clot; generally better to cross arterial anastomosis and do a real angiogram Consider Trerotola device and/or Angiojet if tPA and PTA inadequate If you’ve done everything and still no good thrill, problem is probably the arterial anastomosis; critique your angiogram and re-dilate Central veins are rarely the cause of AV graft/fistula thrombosis, but consider PTA or stent if rest of circuit is patent Dilating venous stenoses can be very painful; consider lido injection at site of stenosis Keep working until you get a uniform thrill without pulsatility
POST-PROCEDURE CARE OK to use graft or fistula immediately Purse-string suture can be removed at next dialysis
COMPLICATIONS Venous rupture Especially upper cephalic vein “cephalic arch” in AV fistulas Start with manual compression or balloon tamponade (2 5-minute cycles) If fails, consider stent or stent-graft Persistent bleeding from entry sites Usually due to suboptimal X-stitch; does not work if graft/fistula not scarred (<2 months old) May be due to outflow stenosis; consider fistulogram to re-assess PE Theoretical risk from central embolization of clot, but clinically significant PE is quite rare Arterial thrombosis If arterial embolus seen on angiogram, but is not symptomatic and is only partially flow limiting, OK to leave alone (will lyse spontaneously) If symptomatic (cold, painful, pale hand): heparinize Immediate angiography and thrombolysis initiation Occasionally surgical thrombectomy is required, if dislodged clot is old and not lyseable
OUTCOMES Failing fistulas: Technical success rate (<30% residual stenosis) is 80-98% Hemodynamic success rate (normalization of flow/pressure) is 70-90% 6-month primary patency is 50%; 12-month primary patency is 25-50% Clotted grafts: Technical success rate is 90% 3-month primary patency is 40%
CONTROVERSIES Stent grafts (Flair) P h a r m a c o l og i c v s . m e c h a n i c a l Randomized study of 90 patients (48 Pull-type advantages: No gastropexy, 42 not) gastropexy, no balloon which can G tube successful in 100% of pexy rupture, mushroom retention device patients very effective G tube failed (placed into peritoneal Pull-type disadvantages: Sometimes cavity) in 10% of non-pexy patients hard to snare wire in Excoriation or pain seen around pexy stomach, chance of abdominal wall site in 10% of pexy patients infection, may be harder to convert Increased number of punctures can to GJ increase bleeding risk
TROUBLESHOOTING Tu b e o c c l u s i o n Tu b e l e a k a g e 1. Flush with water or saline 1. Secure disc so that balloon is well- 2. Flush with Coca-Cola apposed to inner margin of stomach 3. Pass a wire under fluoro 2. Ensure that balloon is not obstructing gastric outlet 4. Replace tube 3. Antacids 4. Local antibiotic ointment 5. Paracentesis (if ascites) 6. Upsize tube 7. Use suture to tighten tract

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Ba sic ir interventions

  • 1.
    BASIC IR INTERVENTIONS A layfellow’s guide
  • 2.
    BASIC IR INTERVENTIONS Venous lines Feeding tubes Biliary drainage AV graft and fistula declots IVC filters
  • 3.
  • 4.
    WHAT LINE, WHEN? PICC Po r t - a - C a t h Hickman 4F or 5F, single or dual-lumen 8F, single lumen 9F, single or dual-lumen Dwell time: Days to months Dwell time: Months to years Dwell time: Months to years Chemotherapy, antibiotics, TPN Intermittent access Frequent or continuous access Chemotherapy, rarely antibiotics Continuous infusions (Pulm or TPN HTN, dobutamine, etc) Quinton/Niagara Pe r m a c a t h 13.5F, dual-lumen 14F, dual-lumen Dwell time: <2 weeks Dwell time: Months to years Short-term hemodialysis or Hemodialysis or expected repeat plasmapheresis plasmapheresis Awaiting AV graft/fistula, or cannot Rapid infusion have AV graft/fistula
  • 5.
    INDICATIONS/CONTRAINDICATIONS Indications: Contraindications (all are relative): Short-term venous access Quinton: None (Quinton, PICC) PICC: None Long-term venous access Port: Active infection, INR (Hickman, Permacath, Port) >1.5, platelets <50, neutropenia Permacath: Sepsis or bacteremia, INR > 2, platelets <50 Hickman: Sepsis or bacteremia, INR >2, platelets <50
  • 6.
    PRE-PROCEDURE Antibiotics Required for Port, optional for Permacath and Hickman, unnecessary for PICC and Quinton Ancef 1 gram IV Alternative for PCN allergy: Clindamycin 600 mg IV or Vancomycin 1 gram IV Review any prior venograms and cross-sectional imaging
  • 7.
    PROCEDURE (QUINTON) 1. Right IJ approach favored (subclavian or femoral if needed) 2. Ultrasound site prior to prepping to confirm vein patency 3. Prep and administer 10 cc lidocaine in skin and soft tissues 4. 21 gauge needle with slip-tip syringe, access vein under ultrasound, aspirate to confirm 5. Pass microwire into RA and place micropuncture catheter 6. Upsize to 035 Amplatz wire, direct into IVC 7. Dilate and place Quinton 8. Flush/aspirate and lock with heparin (1000 units/cc)
  • 9.
    PROCEDURE (PERMACATH/HICKMAN) 1. Initial steps same as Quinton; ensure that IJ access is as low as possible 2. Before removing micropuncture wire, place at desired site of catheter tip (cavoatrial junction to mid-RA) and measure length 3. Once 035 wire in place (in IVC), anesthetize exit site and tract 3-4 finger breadths below clavicle 4. Single blade puncture, tunnel catheter to neck puncture site and pass all the way through up to hub 5. Serial dilation and place peel-away sheath (watch with fluoro) 6. Remove inner dilator and pass catheter into SVC/RA 7. Flush/aspirate and lock with heparin (1000 units/cc for Permacath, 100 units/cc for Hickman) 8. Suture with 2-0 silk or Prolene
  • 11.
    PROCEDURE (PORTACATH) 1. Wide prep, antibiotics and full surgical scrub 2. Initial steps same as Quinton; ensure that IJ access is as low as possible 3. Once 035 wire placed, anesthetize port incision site and pocket (about 4 finger breadths below clavicle) 4. 2 cm transverse incision with 15 blade 5. Open pocket above incision with forceps and finger; should be snug to prevent port flipping 6. Pre-assemble and flush port, attach catheter and tunneler 7. Tunnel catheter through tract and out of neck puncture site and gently pull port into pocket 8. Place catheter over chest and trim to desired length; use micropuncture wire to confirm 9. Serially dilate and place peel-away sheath 10. Pass catheter through peel-away sheath and confirm adequate position with fluoro 11. Peel away sheath and massage catheter smoothly into tract 12. Flush and aspirate port and lock with heparin (100 units/cc) 13. Place 2-3 deep 3-0 Vicryl sutures to approximate incision 14. Place 4-5 subcuticular interrupted 4-0 Vicryl sutures to complete closure 15. Dermabond and place Telfa dressings 16. Consider leaving port accessed (if use within 24-48 hours)
  • 13.
    TECHNICAL TIPS MRvenography can be very useful in patients with multiple venous occlusions With IJ access, keep position of carotid in mind, and direct needle away from it when possible Low IJ access can be aided by accessing just above clavicle from side of ultrasound probe Always place wire down IVC. If difficult, use deep inspiration, or use 5F Kumpe catheter and/or angled glidewire to cannulate When right IJ not available, sequential order of veins to be used: Left IJ, right or left EJ, right or left subclavian, right or left femoral, jugular collateral, transhepatic, transcaval. Usually venous recanalization should be attempted prior to resorting to transhepatic or transcaval lines. Avoid subclavian access on the side of an existing or planned dialysis fistula Use meticulous sterile technique!
  • 15.
    POST-PROCEDURE CARE Keep site clean and dry; no swimming or baths For showering, site should be covered (e.g. Tegaderm) and kept out of direct stream of water Port follow up in clinic in 7 days (call 310-481-7545 for appt) Sutures for Hickman and Permacath can be removed at 2-3 weeks
  • 16.
    COMPLICATIONS Carotid or subclavianartery puncture With needle: Remove needle, hold firm but non-occlusive pressure for 10-15 minutes With dilator/catheter: Surgical consult, can consider closure device and/or balloon tamponade Air embolism Usually occurs when patient takes a forced inspiration at the time of dilator removal from the peel-away sheath; a sucking sound is often heard Air usually passes into outflow tract of right ventricle (may be visible on fluoro); can obstruct pulmonary trunk Leave patient in supine position until air is absorbed (may take up to 20 minutes) Continuous vital sign monitoring; administer oxygen by face mask or 100% non -rebreather If patient not doing well, turn patient on his/her left side and place head down if possible; catheter aspiration Infection Exit site or tunnel infection: local erythema, tenderness, induration or drainage; no systemic symptoms; usually treatable with local wound care and antibiotics; culture exudate if present Catheter-related bacteremia: fever or sepsis; catheter should be exchanged or removed and IV antibiotics required Catheter occlusion Fibrin sheath: forms within a week and may cause catheter dysfunction Can flush but cannot aspirate; venogram to diagnose Attempt tPA first; if fails, consider catheter replacement with or without sheath disruption, stripping
  • 17.
    OUTCOMES Technical success rate nears 100% Catheter infection rates are comparable for lines placed in IR suite and OR 5/1000 catheter-days for Quinton 1-2/1000 catheter-days for PICC 1.3/1000 catheter-days for Permacath/Hickman 0-1/1000 catheter-days for Portacath Asymptomatic catheter-related venous thrombosis occurs in 28-54% Symptomatic catheter-related venous thrombosis occurs in 2.8-16%
  • 18.
    CONTROVERSIES Hickman vs. Groshong Access site Hickman has simple cut tip; Subclavian vein has higher chance of Groshong has valved tip pinch-off syndrome and higher Valved tip prevents need for heparin likelihood of symptomatic occlusion lock of line Femoral vein has higher infection But, no improvement in patency risk Groshong more difficult to place Internal jugular access is favored whenever possible
  • 19.
    TROUBLESHOOTING Catheter occlusion C e n t r a l ve n o u s o c c l u s i o n 1. X-ray to document line position 1. Thrombosis risk: 45% if 2. If position OK, give 2 mg tPA catheter tip in innominate vein; into line and let dwell 2-3 hours 19% if tip in upper SVC; <5% if tip in lower SVC or upper 3. If fails, infuse 1 mg tPA/hour right atrium over 3-4 hours 2. Treat with anticoagulation 4. Catheter stripping from femoral vein for ports and Hickmans 3. If fails, remove device and continue anticoagulation 5. Catheter exchange for Permacaths and PICCs 4. If this fails, can consider lysis
  • 25.
  • 26.
    INDICATIONS/CONTRAINDICATIONS Indications: Contraindications: Long-term nutritional support Colonic interposition Long-term SBO decompression Portal HTN Moderate or large ascites Previous gastric surgery (relative) INR >1.5 Platelets <75K
  • 27.
    PRE-PROCEDURE NPO 8 hours Consider 200 cc of dilute barium suspension given the night prior Consider antibiotics (usually unnecessary) Consider glucagon 1 mg IV at start of procedure
  • 28.
    PROCEDURE (PUSH TYPE) 1. Ultrasound and mark liver edge 2. Place small bore NG tube 3. Insufflate stomach 4. Fluoro to confirm safe window – use lateral if necessary 5. 1% lidocaine, all the way into stomach along expected path (slightly rightward) 6. 3 T-fasteners; watch under fluoro; inject to confirm position 7. Puncture stomach and place 035 Amplatz wire 8. Pre-load 8 mm x 4 cm balloon into 18F G tube 9. Pass balloon/tube over wire, place balloon into tract and fully inflate 10. Advance balloon and tube into stomach as balloon deflates 11. Inflate G tube balloon with 10 cc sterile H20 and secure disk
  • 29.
    PROCEDURE (PULL TYPE) 1. Prophylactic antibiotics (Ancef 1 gram IV) 2. Ultrasound and mark liver edge 3. Place small bore NG tube 4. Insufflate stomach 5. Fluoro to confirm safe window – use lateral if necessary 6. 1% lidocaine, all the way into stomach along expected path (toward fundus) 7. Puncture stomach and place 6F sheath 8. Pass wire down esophagus and snare from stomach using goose-neck snare 9. Secure tube onto wire from oral end and pull wire and tube through mouth and down through stomach and abdominal wall 10. Trim tube and place hub; secure outer bumper against abdominal wall
  • 30.
    PROCEDURE (GASTROJEJUNOSTOMY) 1. Usually used for patients with gastric reflux, aspiration, or poor gastric emptying 2. Initial steps same as push-type gastrostomy 3. Once T-fasteners placed, puncture into stomach and place 6F sheath 4. Use Kumpe catheter and stiff angled glide wire to cannulate pylorus and through duodenum into proximal jejunum 5. Serial dilators with peel-away sheath (22F for 18F GJ tube) or balloon dilation of tract 6. Pass GJ tube over stiff angled glidewire into jejunum; monitor under fluoro 7. OK to use jejunal port immediately 8. Compared to G tubes, GJ tubes: Technically more difficult Clog more frequently Require more expensive elemental diet Require slow infusion to prevent dumping
  • 31.
    TECHNICAL TIPS Do not underestimate G tubes! Review CT scans prior to procedure Maintain stomach inflation for all steps Localize colon and stomach using AP and lateral fluoro Small bowel is only rarely anterior to stomach In difficult cases, use DynaCT Antrum or mid-body are best targets (careful of inferior epigastric artery) Avoid greater and lesser curvatures (gastric/gastroepiploic arteries) Watch all needle advancements into stomach under fluoro (look for tenting at needle tip; use logic and avoid needle over-advancement) If tube does not pass easily, re-inflate balloon, re-inflate stomach, and re-try (don’t force the tube in, may push stomach away instead)
  • 33.
    POST-PROCEDURE CARE Stomach restfor 24 hours (NPO, do not use tube except for decompression) T-fastener removal in 1 week Routine flushing of tube before and after each use Liquefy anything placed through tube (pills should be finely crushed and liquefied)
  • 34.
    COMPLICATIONS Gastrointestinal perforation (especiallytransverse colon) If just needle: OK to withdraw, re-direct, and continue procedure (give antibiotics) If tract dilated or G tube placed: Consult surgery (do not remove tube) Peritoneal positioning leading to peritonitis Be critical of final G tube injection to confirm intragastric position If access to stomach lost during tract dilation, OK to re-puncture and continue; consider antibiotics and longer stomach rest before feeding Wound infection Local skin care; consider Keflex 500 mg PO BID x 7-10 days Consider tube exchange or removal; Consider CT scan to evaluate for abscess Aspiration Consider conversion to GJ tube Catheter falls out Have ER place something in tract (Foley catheter) Can usually re-cannulate established tract within 24 hours of tube dislodgement
  • 35.
    OUTCOMES Technical success rate ~98% Lower morbidity and mortality rate than surgical tube placement Equivalent morbidity and mortality to endoscopic tube placement 2% major complication rate 6% minor complication rate
  • 36.
    CONTROVERSIES Gastropexy? P u l l ve r s u s P u s h ? Randomized study of 90 patients (48 Pull-type advantages: No gastropexy, 42 not) gastropexy, no balloon which can G tube successful in 100% of pexy rupture, mushroom retention device patients very effective G tube failed (placed into peritoneal Pull-type disadvantages: Sometimes cavity) in 10% of non-pexy patients hard to snare wire in Excoriation or pain seen around pexy stomach, chance of abdominal wall site in 10% of pexy patients infection, may be harder to convert Increased number of punctures can to GJ increase bleeding risk
  • 37.
    TROUBLESHOOTING Tu b e o c c l u s i o n Tu b e l e a k a g e 1. Flush with water or saline 1. Secure disc so that balloon is well- 2. Flush with Coca-Cola apposed to inner margin of stomach 3. Pass a wire under fluoro 2. Ensure that balloon is not obstructing gastric outlet 4. Replace tube 3. Antacids 4. Local antibiotic ointment 5. Paracentesis (if ascites) 6. Upsize tube 7. Use suture to tighten tract
  • 38.
  • 39.
    INDICATIONS/CONTRAINDICATIONS Indications: Contraindications (all are relative): Relieve biliary obstruction when Marked ascites ERCP has failed or is not indicated Multiple obstructed, isolated biliary Manage cholangitis segments (sclerosing Diagnosis cholangitis, mets) INR >1.5 Platelets <75
  • 40.
    PRE-PROCEDURE Antibiotics: Zosyn 3.375 grams IV or Ceftriaxone 1 gram IV Review cross sectional imaging Choose desired approach: Right side: Generally easier to perform under fluoro, less radiation to hands Left side: Generally easier to perform under ultrasound
  • 41.
    PROCEDURE 1. Wide prep and insonate liver with ultrasound 2. Advance 21 or 22 gauge Chiba under US and/or fluoro 3. Attach contrast syringe with extension tubing, gentle injection as needle is withdrawn 4. When duct entered, opacify biliary tree with contrast and decide if suitable; if not, repuncture suitable duct 5. Once accessed, pass 018 wire, upsize to Accustick catheter 6. Use 4F glide catheter and 035 angled glide wire to navigate through occlusion (if not infected) 7. Place stiff wire, consider cholangioplasty (4-8 mm, 2 min inflation, high pressure) 8. Dilate tract and place biliary drain (usually 8-10F)
  • 42.
    TECHNICAL TIPS This procedure is painful! Liberal use of narcotics/sedation Do not use very central bile duct access for tube placement, due to increased chance of vascular injury Left access: 1. Use ultrasound liberally 2. Segment 3 is most accessible, but usually posterior to adjacent portal vein 3. Angle rightward with access needle to produce favorable wire trajectory Right access: 1. Be careful of pleural reflection; access below 10 th rib laterally 2. Advance along course of posterior rib toward hilum, parallel to floor 3. Change angulation if no bile duct accessed (more posterior and cranial)
  • 43.
    POST-PROCEDURE CARE Keep site clean and dry; no swimming or baths For showering, site should be covered (e.g. Tegaderm) and kept out of direct stream of water Flushing tube is OK but optional; do not aspirate Benign strictures short course: 1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h 2. Return in 6 weeks, re-inject; if patent, place external drain, cap at 24h 3. If no symptoms develop, remove tube 1-2 weeks later Benign strictures long course: 1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h 2. At 6 weeks, repeat cholangioplasty, upsize to 12F, cap at 24h 3. At 12 weeks, repeat cholangioplasty, upsize to 14F, cap at 24h 4. At 18 weeks, re-assess, if patent, place external drain, cap at 24h 5. If no symptoms develop, remove tube 1-2 weeks later
  • 44.
    AV GRAFT ANDFISTULA DECLOTS
  • 45.
    INDICATIONS/CONTRAINDICATIONS Indications: Contraindications: Elevated venous pressures Infected vascular access Decreased flow (<600 mL/min) Long-segment (>7 cm) Prolonged bleeding after needle stenosis/occlusion – consider removal surgery Arm swelling Severe hyperkalemia – place Quinton instead Thrombosis Nonmaturing fistula (by 3 months) Relative: INR >2.0, platelets <25K
  • 46.
    PRE-PROCEDURE Checkhistory; if >2 interventions in last month, surgery may be indicated Check labs (especially potassium) Palpate fistula and outline anatomy; ensure absence of infection Palpate and document pulses, capillary refill, warmth in affected limb Ultrasound can help delineate anatomy as well as sites of stenosis and best site for access
  • 47.
    PROCEDURE (FISTULAGRAM) 1. Access fistula near anastomosis but pointing toward venous outflow 2. Place micropuncture catheter 3. If flow is present and no clot, perform outflow and central venography followed by blow-back angiogram of the anastomosis 4. Consider oblique views to help define anatomy 5. Interventions as needed
  • 48.
    PROCEDURE (CLOTTED AV GRAFT) 1. Access graft near arterial anastomosis, toward venous outflow; place 6F short sheath 2. 5F Kumpe catheter and glidewire to access axillary vein 3. Central venography 4. Pull-back puffs of contrast until reach area of thrombosis 5. Lace back to sheath with 2 mg of tPA in 10 cc (use most but not all); give 3000-5000 units heparin IV 6. Access graft near venous anastomosis, toward artery; place 6F short sheath; administer remainder of tPA 7. 6 or 7 mm x 4 cm PTA of all venous limb and graft back to the sheath; 90 second inflations for areas of stenosis 8. Pass 4 or 5 mm x 2 cm PTA (or Fogarty balloon) across arterial anastomosis; inflate to 1-2 atm, gently pull across anastomosis and watch for waist; repeat and angioplasty waist if present 9. Kumpe catheter across arterial anastomosis and perform graftogram 10. Repeat venous and arterial PTA as needed, +/- mechanical 11. X-stitch to close puncture sites (3-0 Vicryl)
  • 49.
    TECHNICAL TIPS Access sheaths should not cross (reduces flow) May need Conquest balloon or cutting balloon for resistant venous stenoses Don’t inject clotted graft; always puff contrast to ensure forward flow prior to runs Careful with blow-back angiography, make sure there is no clot; generally better to cross arterial anastomosis and do a real angiogram Consider Trerotola device and/or Angiojet if tPA and PTA inadequate If you’ve done everything and still no good thrill, problem is probably the arterial anastomosis; critique your angiogram and re-dilate Central veins are rarely the cause of AV graft/fistula thrombosis, but consider PTA or stent if rest of circuit is patent Dilating venous stenoses can be very painful; consider lido injection at site of stenosis Keep working until you get a uniform thrill without pulsatility
  • 51.
    POST-PROCEDURE CARE OK to use graft or fistula immediately Purse-string suture can be removed at next dialysis
  • 52.
    COMPLICATIONS Venous rupture Especially upper cephalic vein “cephalic arch” in AV fistulas Start with manual compression or balloon tamponade (2 5-minute cycles) If fails, consider stent or stent-graft Persistent bleeding from entry sites Usually due to suboptimal X-stitch; does not work if graft/fistula not scarred (<2 months old) May be due to outflow stenosis; consider fistulogram to re-assess PE Theoretical risk from central embolization of clot, but clinically significant PE is quite rare Arterial thrombosis If arterial embolus seen on angiogram, but is not symptomatic and is only partially flow limiting, OK to leave alone (will lyse spontaneously) If symptomatic (cold, painful, pale hand): heparinize Immediate angiography and thrombolysis initiation Occasionally surgical thrombectomy is required, if dislodged clot is old and not lyseable
  • 53.
    OUTCOMES Failing fistulas: Technical success rate (<30% residual stenosis) is 80-98% Hemodynamic success rate (normalization of flow/pressure) is 70-90% 6-month primary patency is 50%; 12-month primary patency is 25-50% Clotted grafts: Technical success rate is 90% 3-month primary patency is 40%
  • 54.
    CONTROVERSIES Stent grafts (Flair) P h a r m a c o l og i c v s . m e c h a n i c a l Randomized study of 90 patients (48 Pull-type advantages: No gastropexy, 42 not) gastropexy, no balloon which can G tube successful in 100% of pexy rupture, mushroom retention device patients very effective G tube failed (placed into peritoneal Pull-type disadvantages: Sometimes cavity) in 10% of non-pexy patients hard to snare wire in Excoriation or pain seen around pexy stomach, chance of abdominal wall site in 10% of pexy patients infection, may be harder to convert Increased number of punctures can to GJ increase bleeding risk
  • 55.
    TROUBLESHOOTING Tu b e o c c l u s i o n Tu b e l e a k a g e 1. Flush with water or saline 1. Secure disc so that balloon is well- 2. Flush with Coca-Cola apposed to inner margin of stomach 3. Pass a wire under fluoro 2. Ensure that balloon is not obstructing gastric outlet 4. Replace tube 3. Antacids 4. Local antibiotic ointment 5. Paracentesis (if ascites) 6. Upsize tube 7. Use suture to tighten tract