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SERIES "THORACIC IMAGING"

Edited by P.A. Gevenois and A. Bankier

Number 1 in this Series

Imaging guided thoracic interventions

B. Ghaye, R.F. Dondelinger

Imaging guided thoracic interventions. B. Ghaye, R.F. Dondelinger. #ERS JournalsLtd 2001.ABSTRACT: Interventional Radiology is a technique based medical specialty, using allavailable imaging modalities (uoroscopy, ultrasound, computed tomography, magneticresonance, angiography) for guidance of interventional techniques for diagnostic ortherapeutic purposes.

Actual, percutaneous transthoracic needle biopsy includes core needle biopsy besidesne needle aspiration. Any pleural, pulmonary or mediastinal uid or gas collection is

amenable to percutaneous pulmonary catheter drainage.Treatment of haemoptysis of the bronchial artery or pulmonary artery origin,

transcatheter embolization of pulmonary arteriovenous malformations and pseudoa-neurysms, angioplasty and stenting of the superior vena caval system and percutaneousforeign body retrieval are well established routine procedures, precluding unnecessarysurgery. These techniques are safe and effective in experienced hands.

Computed tomography is helpful in pre- and postoperative imaging of patients beingconsidered for endobronchial stenting. Many procedures can be performed on anoutpatient basis, thus increasing the cost-effectiveness of radiologically guidedinterventions in the thorax.Eur Respir J 2001; 17: 507528.

Dept of Medical Imaging, UniversityHospital Sart Tilman, Liege, Belgium.

Correspondence: B. Ghaye, Dept ofMedical Imaging, University HospitalSart Tilman B 35, B-4000 Liege,Belgium.Fax: 32 43667772

Keywords: Arteriesinterventional radiologystentstherapeutic blockadethoraxtransthoracic biopsy

Received: October 10 2000Accepted after revision December 272000

Percutaneous nonoperative procedures in the chest

were applied before the advent of imaging. LEYDEN [1]performed the rst transthoracic needle lung biopsy in1882 to conrm pulmonary infection. During the rsthalf of the twentieth century, lung biopsy was mainlyused to establish the microbiological diagnosis of ex-tensive infectious lobar consolidation, which was easyto localize. Percutaneous needle sampling in the chesthowever, fell into disrepute, due to an unacceptablehigh rate of complications, caused by the large calibreof needles. Despite the use of smaller needles, patho-logists remained reluctant to formulate a diagnosis onsmall samples or smears. Fluoroscopically guided bron-chial brush biopsy was described in the sixties [2]. At thesame time, the innovating work of NORDENSTRO M and

ZAJICEK

[3] at the Karolinska Hospital in Stockholmpopularized the technique of transthoracic ne needlesampling in the chest. The rate of pneumothorax wasdramatically reduced with the systematic use of smallgauge needles, although the rate of inadequate cellularmaterial or false negative diagnoses in the conrma-tion of malignancy persisted in the 1525% range. Falsepositive diagnoses did not exceed 2%. Transthoracicneedle biopsy of mediastinal lymph nodes was des-cribed by a transjugular, a paraxiphoid or a paraver-tebral approach [4, 5]. These transthoracic approacheswere adopted on a routine basis, when computed to-mography (CT) became available. Mediastinoscopywas also developed at the Karolinska Hospital, follo-

wing the description of"articial pneumomediastinum"

[6]. A rigid cystoscope was introduced by Nordenstro min the mediastinum under combined uoroscopic anddirect vision control (Nordenstro m, Karolinska Hospi-tal, Stockholm, Sweden; personal communication).Percutaneous mediastinal puncture however, was notwidely carried out before the advent of CT with reducedscanning times. Percutaneous insertion of drainagecatheters in uid collections of the pleura, lung ormediastinum, guided by uoroscopy or CT wasintroduced in the late seventies using basic catheter-guidewire techniques, which were applied already in theabdomen [7]. Arteriography of the bronchial arterieswas also described in Sweden in the sixties. Chemo-infusion in bronchomediastinal arteries for treatment of

inoperable bronchial carcinoma was the rst clinicalapplication of vascular interventional techniques in thechest, but was not widely spread [8]. Catheterembolization of bronchial or systemic arteries fortreatment of haemoptysis was introduced in the nextdecade [9]. Miniaturization of catheters and renementin embolic agents denitely established bronchial arteryembolization as an accepted technique. Similar vascularocclusion techniques were applied in pulmonaryarteries, rst for treatment of haemoptysis, then as ameans of occlusion of pulmonary arteriovenous stula,with coils or detachable balloons [10, 11].

When adequate vascular catheters, wires andother devices, such as snare loops became available,

Eur Respir J 2001; 17: 507528Printed in UK all rights reserved

Copyright #ERS Journals Ltd 2001European Respiratory Journal

ISSN 0903-1936

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percutaneous foreign body retrieval from the heart orpulmonary arteries became applicable [12]. The intro-duction of expandable metal vascular stents furtherbroadened the spectrum of closed minimally invasivetechniques in the chest, allowing for minimally invasivetreatment of superior vena cava (SVC) obstruction withan immediate clinical result [13]. The most prominentinterventional radiological techniques in the chestmentioned earlier will be discussed in this paper.

Percutaneous nonvascular interventions

The various percutaneous nonvascular applicationsthat are in clinical use in the authors9 department arelisted in table 1.

Imaging guidance modalities

Imaging techniques used for the guidance of inter-ventional procedures include uoroscopy and cross-section imaging or a combination of both [14]. Acomparison of the different imaging modalities forpercutaneous biopsy or drainage of thoracic lesions isgiven in table 2.

Fluoroscopy

Uni- or bi-planar uoroscopy was the rst techniqueto be used as a guidance of percutaneous transthoracicneedle biopsy (TNB) and drainage of uid collections[3, 1627]. Advantages are familiarity to most opera-tors, real-time control of the procedure, and its wide

availability in radiological departments. Fluoroscopyallows adjustment of the tip of a catheter previouslyinserted into a uid collection with ultrasonography(US) or CT control [28]. Opacication of stuloustracts is best documented with uoroscopy and plainlms, in some occasions in combination with CT.

Computed tomography

CT offers exquisite anatomical display of all thethoracic structures and allows percutaneous access toall spaces with equal ease [14, 1923, 2833]. Intrave-nous contrast medium injection is mandatory foridentication of necrosis, uid content, normal vascularstructures and false aneurysm located in an abscesswall, and also contributes to a precise delineation of alesion with regard to the anatomical environment. CT isparticularly useful for guiding puncture of a mediastinallesion and an intrapulmonary lesion that is difcult tolocalize with uoroscopy alone [29, 34]. CT allows fordetermination of an optimal cutaneous entry point in

such a way as to avoid transgression of a pleural ssureor puncture of large vessels, bronchi and the oesopha-gus. The spiral scanning capability was not provedsuperior to sequential scanning [35]. Real time CT(uoro-CT or continuous CT) is now widely availableand combines the advantages of cross-section imagingand real time control of the procedure [36, 37].

Ultrasonography

Apart from it being the primary imaging guidancefor biopsies of the chest wall or pleural lesions as well aslesions located in the anterior mediastinum [38, 39],ultrasonography (US) is particularly indicated to guide

bedside percutaneous aspiration and catheter drainageof a pleural or pericardial uid collection, even of onlysmall amounts [1922, 28, 4043]. A subpleural pul-monary effusion and some pulmonary lesions with aparietal contact can also be punctured with US con-trol [4447]. The percutaneous approach is performedin the patient9s position that optimally displays accessto the lesion.

Magnetic resonance

Guidance of percutaneous interventions is a promis-ing application of magnetic resonance (MR) [48, 49].Little clinical experience is gained so far in thoracic

interventions.

Table 1. Percutaneous imaging guided nonvascularinterventions in the thorax

FrequentFine needle biopsy or uid aspiration in the lung, pleura

and mediastinumCatheter drainage of pleural, lung or mediastinal uid or

air collectionsInfrequent

Pre-operative localization of a lung noduleDrainage of tension mediastinumPercutaneous block of the upper sympathetic chainBrachytherapy, electrochemical or radiofrequency treat-

ment of pulmonary malignancy*Treatment of secondary pulmonary aspergilloma*

*: No personal experience.

Table 2. Comparison of imaging techniques for guidance of thoracic interventions

Modality Cost Availability Radiation(patient/physician)

Length ofprocedure

Access tocentral lesion

Real timecontrol

Mobilization ofthe patient

Fluoroscopy z zzz z/z z z zzz zzzCT zz zz zz/0 zzz zzz 0 zFluoro-CT zz zz zz/z zz zzz zz zUltrasonography z zzz 0/0 zz 0 zzz zzzMR zzz z 0/0 zzz zzz z z

Modied from KLEIN and ZARKA [15]. CT: computed tomography; MR: magnetic resonance. The plus symbols represent aqualitative assessment; the greater the number of plusses the greater the parameter.

508 B. GHAYE, R.F. DONDELINGER

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Transthoracic needle biopsy

In general, percutaneous tissue sampling of a pul-monary, pleural, or mediastinal lesion is performedwhen histological diagnosis will modify staging ofthe disease, inuence therapeutic strategy, and whenthe diagnosis cannot be established by bronchoscopictechniques. TNB can be used as a less invasivealternative to mediastinoscopy in some mediastinallesions as well as medical thoracoscopy in pleuralpathologies.

Indications

Main indications for TNB are [14]: indeterminatethoracic nodule or mass; pulmonary nodule suggestiveof malignancy, surgery being postponed after chemo-

therapy and/or radiotherapy or replaced by thesetreatments; nodule in a patient with a clinical historyof extrapulmonary primary malignancy, the patientbeing in clinical remission or presenting multipleprimary malignancies; residual nodule following ra-diotherapy or chemotherapy; tissue sampling for the-rapeutic sensitivity tests, measurements of tumourmarkers, hormonal dependence, deoxyribonucleicacid (DNA) analysis, etc; chronic diffuse pulmonaryinltrate and evaluation of suspected focal infectiousdisease in normal or immunocompromised patients.The need for preoperative diagnosis of a solitarypulmonary nodule varies between institutions, anddepends on the pretest probability of diagnosing alesion that would obviate an unnecessary surgicalthoracoscopy or thoracotomy [15]. The technique isfaster, better tolerated and less expensive than surgery.Percutaneous puncture could also be indicated in

a) b)

c) d)

Fig. 1. Percutaneous transthoracic needle biopsy. a) 11 mm left parahilar nodule (arrow) in a 65-yr-old female. The procedure is per-formed in right lateral decubitus with a 20 G aspiration needle. Pathology revealed neuroendocrine tumour, conrmed by subsequentsurgery. b) 70-yr-old male presenting with a recent history of hepatocellular carcinoma and a past history of melanoma. Transthoracicneedle biopsy (TNB) of a 7 mm nodule located in the right upper lobe (arrow) showed metastasis of melanoma. c) 20 mm right hilarmass (arrow) in a 53-yr-old male. Bronchoscopy was unremarkable. TNB performed during contrast medium injection to avoid vascu-lar injury showed small cell lung carcinoma. d) Asymptomatic 45-yr-old female working in a microbiology dept, and presenting with a35 mm mass (arrow) located in the right upper lobe. Bronchoscopy, bronchial biopsy and bronchoalveolar lavage were negative. TNBdemonstrated positive culture for Mycobacterium tuberculosis.

509IMAGING GUIDED THORACIC INTERVENTIONS

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localization of a lung nodule with a wire or a hook, orpleural tagging prior to video-assisted thoracic surgery(VATS) [5053]. All mediastinal compartments areaccessible to TNB, which is a useful alternative or add-

on to mediastinoscopy or mediastinotomy for cytologicor histologic diagnosis of a hilar or mediastinal massand for staging of lung cancer.

Contra-indications

There is virtually no absolute contra-indication toTNB [14, 54]. A vascular structure, hydatid cyst,meningocele or mediastinal pheochromocytoma isusually correctly diagnosed with imaging and/orlaboratory tests. Coagulation disturbances should berecognized and corrected before sampling. Puncture ofonly one functional lung, chronic respiratory insuf-ciency, pulmonary arterial hypertension, cardiac insuf-ciency and severe emphysema are relative contra-indications that may increase the complication rate ofTNB or render any complication more signicant.Dyspnoea or intractable cough or any other inabilityof the patient to cooperate may be overcome by theuse of real time guidance techniques, such as uoros-copy, US, or uoro-CT and, if possible, appropriate

medication.

Results

TNB has an accuracy varying 8095% in theconrmation of pulmonary malignancy or malignantmediastinal adenopathy [14, 29, 34, 5563]. The nega-tive predictive value of pulmonary biopsy is 8496%and false positive results are noted in 24% [3, 64].The diagnostic accuracy for small nodules with adiameter ofv2 cm is similar to that of larger lesions inexperienced hands [65, 66] (g. 1). A large number ofcutting or aspiration needles, including automatic

guns, with a needle calibre ofv1 mm and a variabletip design are currently used. Almost all needles allowcytological and histological sampling and give similarrates of results and complications concerning diag-nosis of malignant or infectious disease. A specicbenign diagnosis is more frequently established usinga core biopsy needle than on aspiration of clusters ofcells (44100% versus 1247%) [6774]. Cutting needlebiopsy also provides sufcient diagnostic material inpatients with mediastinal lymphoma to guide therapyin 8195% of patients, as well as in diffuse pleuralthickening [15, 67, 7579] (g. 2). If the sampledmaterial is inadequate or insufcient, but there is acytologic or clinical suspicion of malignancy, biopsy

should be repeated.

Complications

The most common complications of TNB are pneu-mothorax and haemoptysis. The incidence of pneu-mothorax varies 860%, with a mean of 20%. Lessthan 5% of patients have persistent clinical symptomsand require aspiration or drainage [14, 18, 19, 25].Factors inuencing pneumothorax are: chronic obst-ructive pulmonary disease, especially emphysema, age,poor patient collaboration, experience of the operator,duration of the procedure, number of transpleural

a)

b)

c)

Fig. 2. Percutaneous transthoracic pleural biopsy. Right pleuralmasses in a 33-yr-old female with a past history of invasive

lympho-epithelial thymoma treated by surgery and radiationtherapy 3 yrs earlier. a) Axial computed tomography (CT) slicesdemonstrate mild right pleural thickening (arrow) in contact withthe 9th vertebral body and rib. b) Three-dimensional reconstruc-tion (surface-shaded display) shows an endopleural view of thepleural surface with a posterior bulging corresponding to thendings of the native scan. Note also two pleural masses locatedalong the diaphragm (arrowheads). c) Transthoracic needlebiopsy (TNB) of the posterior pleural thickening conrmed recur-rent thymoma.


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needle passes, diameter and exibility of the needle,depth and diameter of the target, difculty of loca-lization, cavitary lesion, and mechanical ventilation.Preoperative recognition of risk factors may lead totheir correction, by administration of antitussives orbronchodilatators [54], or to the use of more sophis-ticated techniques, such as a co-axial needle technique,using a larger needle as a guide. In all cases, trans-gression of the needle through bullae should be avoidedand the needle path through the normal lung shouldbe kept to a minimum [80, 81] (g. 3). Haemorrhage,with or without haemoptysis, is encountered in v10%of TNB, most of which are self-limited [14, 55, 64].Other complications, such as malignant seeding alongthe needle tract or air embolism, have become excep-tional observations since the introduction of neneedle biopsy [82, 83]. TNB related death rate is esti-mated at 0.02% [55].

Clinical usefulness and cost-effectiveness of transthoracicneedle biopsy

A comparison of different diagnostic techniques oflung lesions is given in table 3. A recent study on theinuence of TNB on treatment showed that mana-gement was altered in 51% of patients and unaltered,i.e. conrmed the diagnosis of a resectable malig-nancy or provided nondiagnostic results in 49%.Surgery was avoided in 83% of biopsies that alteredpatient treatment [84]. When the pretest likelihood ofmalignancy of a resectable lesion is high, proceedingdirectly to thoracotomy is appropriate since pre-operative TNB is unlikely to alter patient management[15]. Otherwise, TNB and beroptic bronchoscopy(FOB) must be considered complementary and TNBperformed only after a negative FOB. In indetermi-nate pulmonary nodules, VATS may be the method of

a) b)

c) d)

Fig. 3. Articial widening of the extrapleural space for safe transthoracic needle biopsy (TNB) of mediastinal lesion by an extra-pleural approach. A 66-yr-old male presented with dysphagia and altered general condition for since 6 months. Chest radiographyshowed a middle mediastinal mass. a) Computed tomography (CT) conrms a large mediastinal subcarenal soft tissue mass (arrow).Flexible broscopy was unremarkable. Transcarinal needle biopsies were negative. b) CT guided TNB was performed in a prone posi-tion. Absence of extrapleural fat prohibits a safe mediastinal access (arrowhead). c) Widening of the extrapleural space was obtainedby injection of 50 mL of saline (arrowhead), which displaces the pleura laterally. d) Using a coaxial technique, a small cutting needlewas advanced into the lesion through a larger outer needle. Pathology showed poorly differentiated adenocarcinoma.


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choice, providing simultaneous diagnosis and treat-ment and reducing total cost (table 3).

Percutaneous drainage of thoracic uid collections

Image guided percutaneous aspiration or drainageof uid (or air) collection is considered a valid alter-native to surgery. Increased safety and effectivenesscompared to blind techniques have been largelydemonstrated. Any collection located in the pleural

space, pericardium, lung or mediastinum can beaspirated or drained percutaneously with catheterplacement under imaging guidance.

Pleural collections

Pleural effusions, including empyema, haemothorax,chylothorax and pneumothorax can be considered forpercutaneous closed catheter drainage.

Empyema. Indications for catheter drainage depend onthe evolutionary stage of the pleural effusion, accordingto the classication of LIGHT [8587]. The early stage(exsudative phase) corresponds to the secretion of a

protein rich uid by the pleura. This is a mandatorytransitional phase for empyemas and does not requiredrainage. The second stage (brinopurulent phase) ischaracterized by a viscous and opaque uid withincreased cellularity. Deposition of brin layers onthe pleural surface promotes the formation of pleuralpockets and progressive lung entrapment. Medicaltreatment without effective uid drainage might fail.The third stage (organizing phase) is characterized bybroblastic inltration of the pleura, limiting theexpansion of the underlying lung due to pleural peels.Early drainage of a complicated effusion is necessaryto prevent progression to the organized phase, whichrequires surgical decortication. In surgical treatment,

blind placement of a thoracostomy tube (30F34F) isfollowed by open surgical drainage if unsuccessful,although some surgeons recommend early open drai-nage, and pleural decortication, as the initial thera-peutic approach [85, 88].

Imaging guided percutaneous drainage avoids thepotential failures associated with blind chest tubeplacement, which can occur in about 50% of patientsdue to inadequate positioning of the tube or to un-drained satellite pleural pockets [86, 87]. The size ofthe percutaneous catheters that are in regular usevaries from 7F30F and is chosen according to theviscosity of the uid to be drained. CT discloses allsatellite noncommunicating pleural pockets, that are

drained with multiple catheters. Pleural uid, which isencapsulated in a ssure can also be adequately drainedwith CT control, most often without transgression ofnormal lung by the catheter. Technical success isachieved in almost all cases. Clinical success is achievedin 7089% of the patients treated in a rst intent,depending on the stage of empyema [14, 17, 2022, 25,27, 28, 31, 32, 41, 42]. A similar success rate of 80% isobtained in patients treated in a second intent followingfailed surgical chest tube drainage [14, 17, 2123, 27,

28]. Failure of percutaneous drainage varies 1130%,and usually occurs in chronic empyema (stage III),when extensive pleural peels have formed, which mayprevent catheter insertion, or the cavity to collapse andobliterate. CT may have its difculties to accuratelydifferentiate between the brinopurulent and organiz-ing phase of empyema [89]. Medium sized catheters arebetter tolerated by the patient than large thoracostomytubes, but their lumen is more prone to obstruction bybrin products. Intrapleural injection of brinolyticagents was recently proven to be efcient in preventingbrin deposit and formation of secondary loculation ofthe empyema, with a clinical success rate of 62100%[14, 23, 26, 90104]. Local instillation of brinolytics

also reduces the number of drainage catheters, that arenecessary to drain all loculations, duration of drainageand hospitalization and prevents brosis of the pleuralsurface (g. 4). Table 4 summarizes the basic principlesand recommendations for successful treatment of com-plicated pleural empyema. Overall, the added cost ofimaging guidance is largely compensated for by thesavings from an increase in clinical success.

Malignant pleural effusion. Recurrent malignantpleural effusion, that is not controlled by systemictreatment, is usually drained with a soft and smallcatheter (8F) followed by pleural sclerosis by intra-

pleural injection of talcum, doxycyclin, bleomycin orother drugs. Advantages of small catheters comparedto classic large-bore thoracostomy tubes are the possi-bility of treatment on an outpatient basis and increas-ed patient comfort. Advantages of imaging guidanceis the proper insertion of the catheter inside thepleural cavity, thus avoiding injury of a pleural mass,which may bleed during catheter insertion, nonrecog-nition of persistent undrained loculations and uncom-plete lung re-expansion before pleural sclerosis. Com-plete regression of a malignant pleural effusion isobtained in 5381% and partial resolution in up to95%, which is a similar response rate than obtainedwith large thoracostomy tubes [24, 43, 105107].

Table 3. Comparison of different diagnostic modalities of pulmonary lesions

Technique Availability Total cost includinghospital stay N

Diagnosticaccuracy %

Pneumothorax % Diagnosis and treatment

Bronchoscopy zzz 1 3090 13 zTNB zzz 12 8095 860 -VATS zz 2030 95 100 yesThoracotomy zzz 4080 y100 100 yes

TNB: transthoracic needle biopsy; VATS: video-assisted thoracic surgery; N: mean cost of bronchoscopy. The plus symbolsrepresent a qualitative assessment, the greater the number of plusses the greater the parameter.


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Haemothorax. Post-traumatic haemothorax is usuallydrained by large-bore surgical chest tubes. In selectedcases with persistent intercostal or phrenic artery ble-eding, angiography and transcatheter embolization isindicated before drainage. Long-lasting multilocu-lated haemothorax is an indication for image-guidedcatheter drainage. Fibrinolytic agents can be safely

injected in a pleural haematoma at 1 week followingtrauma [97, 98] (g. 4). Uncontrolled intrapleuralbleeding is an absolute contra-indication of intra-pleural brinolysis.

Pneumothorax. Postbiopsy or spontaneous pneumo-thorax can be drained percutaneously with a smallcalibre catheter (g. 5). Success rate of drainage ofiatrogenic pneumothorax is 7597%, the vast majorityresolving within 2472 h [18, 19, 25, 86, 107, 108].Catheters can be connected to a one-way Heimlichvalve. Recurrent pneumothorax can be treated withchemical pleurodesis if surgical therapy is not an option.

Pulmonary collections

Abscess. Pyogenic pulmonary abscesses rarely occurtoday, owing to progress in antibiotic treatment anda more efcient eradication of the cause. When resis-tant to medical treatment, postural and bronchoscopicdrainage, lung abscess is amenable to percutaneous

catheter drainage before considering surgery [14].Abscesses frequently present with a large pleuralcontact, which allows percutaneous insertion of a 7F14F catheter without transgression of normal lungparenchyma (g. 6). Resolution of the abscess is ob-tained in 73100% following 1015 days of drainage[7, 30, 31, 33, 40, 109113]. Pulmonary abscesses mayhave a thick wall and complete collapse of the cavitymay take 45 weeks. Decompression should be per-formed slowly to avoid rupture of a vessel or aRasmussen pseudoaneurysm incorporated in theabscess wall. Surgery remains necessary when exten-sive necrotizing pneumonia or life-threatening haemorr-hage has occurred [14].

a) b)

c) d)

Fig. 4. Percutaneous drainage of pleural collection. A 64-yr-old male with chronic obstructive pulmonary disease (COPD) presentedwith right multiloculated pleural collection, following surgical drainage of pneumothorax complicated by superinfected hemothorax. a)Contrast-enhanced spiral computed tomography (CT) section demonstrates a large multiloculated pleural collection. Areas of high den-sities (arrowheads) suggest presence of fresh clot. b) Aspiration with a Teon-sheathed catheter conrms the presence of blood; a 24Fchest tube (arrow) was inserted in the dependant part of the collection. Cultures were positive for Escherichia coli. 200,000 IU of uroki-nase were injected per day for 5 days. c) Spiral CT control demonstrates regression of the collection and persistence of an intrassuralcollection (arrow). Urokinase injection was continued for 3 more days before chest tube removal and discharge of the patient. Totaldrainage volume was 1200 mL. Note on gures b) and c) 4 to 5 mm pleural thickening at the time of drainage. d) High-resolutioncomputed tomography (HRCT) at 1 yr demonstrates complete regression of pleural thickening, with subnormal expansion of the rightlower lobe.


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Aspergilloma. Life-threatening haemoptysis due tointracavitary aspergilloma may be recurrent, despitean initially successful bronchial embolization, andeventually require surgical resection [114120]. Openthoracotomy however, can be contraindicated insome patients who present with a severe underlyingpulmonary condition [118, 120]. Transthoracic in-stillation of amphothericin B has been described witha success rate of 50% for resolution of the asper-gilloma and 75100% for acute control of hae-moptysis [117121].

Pneumatocele and bulla. Percutaneous drainage ofinfected or tension pulmonary pneumatocele has beendescribed [14, 122]. A percutaneous diagnostic aspi-ration with an 18-Gauge needle can precede catheterinsertion in doubtful cases, as bullae may frequentlycontain an air uid level, without infection.

Mediastinal collections

Abscess. Mediastinal abscesses are challenging totreat by a closed percutaneous approach, as overall

Table 4. Basic principles of image guided drainage(modied from MOULTON) [87]

Reasons for failed blind-inserted chest tubeMalposition

Imaging guidanceViscosity

Adapted size of the catheter or tubeFibrin deposits

Fibrinolytic agentsStage III pleural peels (w6 weeks)

DecorticationProper use of imaging guidance

Accurate assessment of the underlying pathologyPlanning of drainage procedureEvaluation of drainage outcome

Initial aggressive catheter management is the key point ofsuccess

Multiple loculationsMultiple cathetersFibrinolytic agents

Use of intracavitary brinolytic agentsAllows complete evacuation of brinous uidPartially debride pleural surfaceFacilitate re-expansion of the underlying lungShould never be used in a possibly malpositioned chest

tube

a) b)

c) d)

Fig. 5. Percutaneous drainage of loculated pneumothorax. A 37-yr-old female with a past history of multiple sclerosis presented withsevere dyspnoea and temperature. Chest radiography showed a right pneumothorax, pulmonary infection and large bullae in the rightapex. a) Insertion of 3 large-bore chest tubes failed to resolve a pneumothorax located in an antero-inferior position (arrowheads). b)and c) Spiral computed tomography (CT) conrmed basal pneumothorax (star) and right lower lobe atelectasis with pleural effusion oflimited volume. A previously blindly placed chest tube is located inside the lung parenchyma, and surrounded by areas of pulmonaryhemorrhage (arrowhead). Laterally, adhesions have formed between the parietal and visceral pleura. d) A 9 F pigtail catheter (arrow-heads) was inserted under CT guidance in the anterior costo-diaphragmatic sulcus and drained air and 200 mL of sterile uid. Subse-quent chemical pleurodesis was performed through the pleural catheter.


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prognosis of the patient is usually poor. Mediastinalcollections can be drained under CT guidance usinga parasternal catheter approach for collections loca-ted in the anterior mediastinum (g. 7) and aposterior paraspinal approach for safe access to theposterior and middle mediastinal compartments [14,27].

When a mediastinal abscess is associated withoesophageal perforation, an oesophageal catheter canbe inserted in the mediastinum over a guide wirethrough the oesophageal tear [123]. The few reportedseries indicate a success rate of 83100%, but 30 daysmortality is high, owing to the underlying disease [31,123125].

Pericardial effusion. Most pericardial effusions aredrained under US control using a subcostal or asubxyphoid approach [126]. When US fails, uid canbe drained under CT guidance, by an atypical leftanterolateral approach [127] (g. 8).

Tension pneumomediastinum. Tension pneumomediasti-num usually results from barotrauma in mechanicallyventilated patients. A tension mediastinal emphysemamay compress the large mediastinal veins and theheart, leading to pseudotamponade which urges forrapid decompression. The usual treatment is media-stinostomy. Percutaneous insertion of a 12F or 14Fcatheter with sideholes into a retrosternal media-stinal gas collection under CT guidance is an alter-native emergency treatment [128].

Others. Ectopic pancreatic pseudocysts, pleuroperi-cardial, parathyroid or bronchogenic cysts, necrotictumours, lymphoceles and haematomas can be drai-ned or aspirated percutaneously using imaging gui-dance [14].

Vascular interventions

Vascular interventions that are in clinical use arelisted in table 5.

a) b)

c) d)

Fig. 6. Percutaneous drainage of pulmonary abscess. A 55-yr-old male with a past history of hemilaryngectomy for squamous cell

carcinoma and recurrent episodes of aspiration presented with elevated temperature and altered general condition. a) Contrast-enhancedcomputed tomography (CT) demonstrates a 5-cm pulmonary abscess (star) located in the right middle lobe. b) An 8F pigtail catheterwas inserted in the abscess under CT guidance through the large thoracic wall contact of the abscess. Forty mL of pus were aspirated.Thirty mL were drained during the next 3 days. Cultures were negative. c) CT control on the third day showed partial collapse of thecavity, lled by air and surrounded by parenchymal consolidation. The catheter was removed. d) CT control obtained 3 months latershowed complete disappearance of the lesions and a plate-like atelectasis (arrowhead).


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This section focuses on the treatment of haemo-ptysis, pulmonary arteriovenous malformation andpseudoaneurysm, superior vena cava obstruction andpercutaneous retrieval of vascular foreign bodies.

Bronchial artery embolization

Indications

Haemoptysis can be classied as massive (w300 mLin 2448 h), moderate (3 episodes of w100 mLwithin a week) and chronic (quantitatively smallepisodes of haemoptysis repeated over the course ofweeks or months). Massive haemoptysis carries a highmortality rate in patients treated conservatively, andmany patients are unt for lung resection. Whensurgery is performed in an acute situation, morbidity ishigh and a mortality rate of 35% has been reported[129133]. Most frequent causes of bleeding include

tuberculosis, chronic infection, bronchiectasis, asper-gilloma, pneumoconiosis, bronchogenic carcinoma,pulmonary metastasis and pulmonary infarction [132,134136]. Chest radiography and bronchoscopy shouldbe obtained immediately to localize the site of bleeding.CT may be considered in noncritical patients to searchfor the underlying cause or determine the exact bleedingsite whenever chest radiographs are inconclusive. Incases of massive haemoptysis requiring an urgentembolization, angiography is recommended as theinitial intervention. Following embolization, surgerycan be carried out in a second intent for localizeddisease [133]. In moderate or chronic haemoptysis,bronchial embolization is the only treatment, whenunresponsive to medical treatment in the followingsituation: recurrent haemoptysis following surgery,postradiation lung, unresectable carcinoma, bilateralpulmonary disease, inadequate lung function to tolerate

a)

b)

Fig. 7. Percutaneous drainage of mediastinal collection. A 68-yr-old female presented with epilepsy related to a frontal cerebralhaematoma. Latrogenic bilateral pneumothorax and pneumome-diastinum followed difcult intubation with laceration of the tra-

cheal wall. Pneumothoraces were drained by surgical chest tubes;2 days later, chest radiography showed a large mediastinalwidening. a) Computed tomography (CT) demonstrates an exten-sive hydro-haemomediastinum located in the anterior mediasti-num (arrow). A 9F pigtail catheter (arrowhead) was insertedunder CT guidance, and drained 450 mL of bloody uid in 48 h.b) CT control at 48 h showed complete regression of the collec-tion (arrow).

a)

b)

Fig. 8. Percutaneous pericardial drainage. A 38-yr-old femalepresented with sudden dyspnoea following left pneumonectomyfor tuberculosis complicated by aspergilloma, unresponsive to

medical treatment. a) Echocardiography demonstrated cardiactamponade, conrmed by computed tomography (CT) Percuta-neous insertion of a 5F catheter in the posterolateral part of thepericardial sac under CT guidance allowed aspiration of 410 mLof a sterile bloody effusion. b) Immediate CT control followingcatheter placement and aspiration showed almost completeregression of effusion and increase of volume of the heart cham-bers. The 5F catheter was exchanged for an 8F pigtail catheterto avoid clogging. The catheter was left in place for 72 h anddrained 50 mL of blood. No recurrence.


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resection, failure to localize a bleeding source roent-genographically and/or bronchoscopically, and largetranspleural connections between bronchial and non-bronchial systemic arterial supply.

Technique. A thoracic aortogram is always obtained tomap all bronchial arteries and systemic nonbronchialfeeders of the bleeding site. Selective opacication ofall bronchial arteries is then performed beginningwith the vessels directed to the suspected bleeding

area. Arteries with an increased calibre, and a tor-tuous course and parenchymal hypervascularity arefound (g. 9). Contrast extravasation in the lungparenchyma or in the bronchial lumen is not requiredto decide on embolization. Vaso-occlusion is best per-

formed through a microcatheter that is inserted coaxi-ally through a diagnostic catheter, the tip of which isplaced in the proximal portion of the vessel or at itsostium. Microcatheters, which can be placed selecti-vely distal to the origin of a spinal artery are notocclusive and allow for optimal catheter stability andsafety during embolization avoiding reux of emboli-zation material [136138]. Polyvinyl alcohol particles,gelfoam and dextran microspheres are among theagents that are in frequent clinical use. Additionalbronchial and nonbronchial collaterals (internal andexternal thoracic arteries, periscapular arteries, cervi-cal arteries, intercostal arteries and inferior phrenicartery) are catheterized and may be treated, whentheir contribution to the hypervascular area is shownon angiography [132, 139, 140] (g. 10). Nonbronch-ial systemic collaterals may resume the distal bronch-ial circulation after a previous bronchial embolizationand be responsible for bleeding recurrence [141].

Results. In a review of the recent literature, bleeding(predominantly massive) was controlled in an acutesetting in 7590% of the patients [142]. Bleedingrecurrence rate was 1648%. In one study with long-term outcome, the Kaplan-Meier curves showed 18%of recurrences within 7 days, 24% within 1 month,33% within 6 months and 38% within 1 yr. No fur-ther recurrences occurred 12 yrs after embolization[142]. Recurrence can be caused by incomplete bron-chial embolization, recanalization of an embolized

Table 5. Vascular interventions in the thorax

FrequentBronchial artery embolization

HaemoptysisPulmonary artery embolization

Arteriovenous malformationPseudoaneurysm

Mediastinal vein stenting

Superior vena cava obstructionInfrequent

Vascular foreign body retrievalSystemic artery embolization

HaemorrhageAneurysmVascular malformation

Percutaneous transluminal balloon angioplasty andstenting

Thoracic aorta stent graftingAneurysmDissection

Chemoembolization*Lung cancer

Parathyroid adenoma infarction*Others

*: No personal experience.

a) b)

Fig. 9. Embolization of bronchial arteries. A 71-yr-old malewith a past history of pleuroparenchymal tuberculosis presentedwith chronic episodes of haemoptysis of small amount for 5months. The patient underwent previous bronchial embolizationfor haemoptysis 11 yrs before. a) Arteriography of the right inter-costobronchial trunk demonstrates an increased calibre and a tor-tuous course of the bronchial artery and areas of parenchymalhypervascularity (arrow). Embolization with polyvinyl alcohol par-ticles was performed. b) Arteriography of a common right anda left bronchial arterial trunk showed other areas of abnormalhypervascularity fed by a dilated and tortuous right bronchialartery (arrow). Embolization with particles.

a) b)

d)c)

Fig. 10. Embolization of systemic nonbronchial collaterals(same patient and same procedure as in g. 9). a) Opacica-tion of a dilated fourth right intercostal artery and adjacentmetameric arteries, shows extensive pleural and parenchymalhypervascularization (arrow). Embolization with particles. b)Opacication of the right internal thoracic artery shows a smallparenchymal blush in the lower part of the right hemithorax. Noembolization is required. c) Opacication of periscapular andexternal thoracic arteries. Normal aspect. d) Opacication of theright inferior phrenic artery, showing limited basal pleuropar-enchymal hypervascularization (arrow). No embolization.


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artery, development of extrapulmonary systemic col-laterals (short-term recurrence), or by progression ofthe underlying disease (long-term recurrence) [136,142]. Usually, recurrent haemoptysis responds to asecond embolization procedure. Bleeding from apulmonary artery should be suspected if the bron-chial arteries are angiographically normal or if embolization of the bronchial and nonbronchial arte-ries fails to stop the bleeding.

Complications. Complications are encountered in 1%of the patients. A postembolization syndrome maybe observed (pleuritic pain, fever, dysphagia, leuko-cytosis); it will last for 57 days and responds tosymptomatic treatment [143]. Bronchial wall or oeso-phageal wall necrosis, inadvertent facial or abdo-minal visceral embolization, myocardial infarctionand spinal cord infarction are rare complications thatcan be avoided by proper technique.

Pulmonary artery embolization

Arteriovenous malformation

Indications. Pulmonary arteriovenous malformations(PAVMs) are arteriovenous shunts which represent apotential source of paradoxical emboli through aright to left shunt, without altering pulmonary arterypressure or cardiac output. Other potential compli-cations include systemic oxygen desaturation resultingin polycythaemia, and haemoptysis or haemothoraxcaused by rupture of the aneurysmal sac. MostPAVMs are congenital and multiple, being part ofthe hereditary haemorrhagic telangiectasia (Rendu-Weber-Osler) syndrome, while a minority are acqui-

red, mainly secondary to vascular damage [136,144147]. They can be classied as simple (one seg-mental feeding artery: one draining vein) or complex(several segmental feeding arteries: one or several drai-ning veins) [148, 149]. Before 1980, surgical lobec-tomy or pulmonary wedge resection was the onlyvalid therapy. Selective embolization is at presentconsidered the treatment of choice for PAVMs whichshow a feeding artery superior to 3 mm in diameter.In fact, large shunts are associated with an increasedincidence of paradoxical emboli potentially causingsevere neurological complications [146153]. Multiplemicroscopic shunts are usually present in addition tothe visible stulae and small AVMs may increase in

size during lifetime. Endoluminal embolization offersthe advantage of a maximal preservation of normallung parenchyma around the malformation, particu-larly in patients with multiple and bilateral PAVMs.

Technique. Pre-embolization thin section helical CTwith 3D reconstruction of the PAVM is an importantstep in identifying all small feeding arteries, whichmay be responsible, when not recognized, of persis-tent shunting following embolization of the mainfeeder only [149]. Selective transcatheter embolizationof all feeding arteries is performed with steel coilswith attached cotton strands (g. 11). All catheterand guidewire exchanges and coil introduction into

the catheter are performed "under water" to avoid airembolism to the brain. Compact placement of endo-luminal coils and choice of large "tornado" shapedcoils or use of a controlled coil detachment techni-que are important keypoints for successful treatmentto avoid transstulous coil migration. The site ofgroin access should be alternated in multiple inter-ventions to avoid femoral vein thrombosis.

Results. Closure rate of PAVMs is 98% and results inpalliation of the right to left shunt and probableprevention of haemorrhagic and thromboembolic

complications caused by major PAVMs [136]. Thereis no evidence based benet on patient9s survival.Multiple treatment sessions are needed in 2040% ofcases. Embolization can fail in case of a unrecognizedpersistent feeding artery, recruitment of feeders,including bronchial arteries in 4% of the cases,recanalization of occluded feeders or growth of otherPAVMs.

Complications. Potential complications are encount-ered in v10% of the patients and include pulmonaryinfarction distal to the occlusion, pleurisy, sepsis andretrograde pulmonary embolism in patients withpolycythaemia.

a) b)

c) d)

Fig. 11. Embolization of pulmonary artery vascular malforma-tion (PAVM). A 49-yr-old male presented with polycytaemia inthe department of Haematology. Investigations were noncontri-butive except chest radiography, which depicted a pulmonarymass in the left lower lobe behind the haemidiaphragm. a) Con-trast enhanced spiral computed tomography (CT) shows a soli-tary 3 cm PAVM (arrow) in the left lower lobe. b) 3D-CTreformatting demonstrates a simple angioarchitecture of the mal-formation with one feeding artery (A) and one draining vein (V).Note the division of the feeder in small afferent branches (arrow-heads) before entering the aneurysmal sac. c) Selective angio-graphic opacication shows the same ndings than in gure (b)(arrowheads). d) Angiography control following embolizationwith steel coils of the feeding artery close to the aneurysmal sacin order to preserve surrounding parenchymal vascularization.

Polycytaemia improved in the following weeks.


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Pseudoaneurysm

Destructive processes of any origin, including trauma(particularly iatrogenic, i.e. Swan-Ganz catheter),infection, tumour, and inammatory disease, canerode the wall of a pulmonary or bronchial vessel,and lead to the formation of a pseudoaneurysm [154].Prompt therapy is required, as false aneurysms are atrisk of enlargement and rupture, which can lead tolethal haemoptysis in w50% of the patients [155].Multiple therapeutic procedures have been used tocontrol pulmonary artery bleeding. Palliative mea-sures include Swan-Ganz balloon tamponade of theaffected vessel and endobronchial tube placementwith positive end-expiratory pressure. Surgical mana-gement generally comprises resection of the involvedlobe, or in selected cases, aneurysmectomy [155].Endoluminal catheter embolization of the parentartery with steel coils has emerged as an alternative

noninvasive technique, particularly in emergency cases[154, 156]. Intrasaccular embolization with steel coilshas the advantage of preserving the distal pulmonaryartery and sparing of pulmonary function distal to thepseudoaneurysm [154] (g. 12).

Percutaneous recanalization and stenting of thesuperior vena cava and innominate veins

Rationale

The potential of the venous system to collateralizeand the usually nonacutely lethal nature of SVCobstruction are the main reasons why medical manage-ment and radiotherapy are preferred to other invasivetherapeutic procedures for correction. Percutaneoustransluminal angioplasty (PTA) is rarely successful inlarge vein obstruction, due to elastic recoil of the

a) b)

c) d)

Fig. 12. Endoluminal intrasaccular embolization of pulmonary artery pseudoaneurysm. An 85-yr-old female presented with haemop-tysis 8 days following insertion of a Swan-Ganz catheter. a) Contrast-enhanced spiral computed tomography (CT) demonstrates a 3 cmpseudoaneurysm located in the internal segment of the middle lobe (arrow). b) Angiographic selective catheterization of the internalsegmental artery of the middle lobe conrmed the pseudoaneurysm. Intrasaccular embolization of the pseudoaneurysm was performedby lling with ten 15 cm-long, 2 cm-diameter steel coils. c) Angiographic control showed complete occlusion of the pseudoaneurysmand normal perfusion of the middle and lower lobe branches. d) Contrast-enhanced spiral CT scan conrmed complete thrombosis ofthe pseudoaneurysm.


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venous wall and/or persistent perivascular compression.The rationale for using expandable metal stents inbenign and malignant SVC obstruction is the immedi-ate and permanent achievement of venous patency.

Indications

Potential indications for percutaneous stenting of theSVC and innominate veins are mainly primary orsecondary malignant tumours with mediastinal loca-tion, such as bronchogenic carcinoma, lymphoma, ormetastatic adenopathy and benign stenoses related tocentral venous lines, haemodialysis shunts, and rarelypostoperative anastomotic stenoses, or brosing med-iastinitis [13, 157161].

The advantage of endoluminal desobstruction overradiation therapy or chemotherapy is the immediatecorrection of disabling symptoms and the still possibleapplication in patients who have already received themaximum radiation dose. Patients with imminent SVCobstruction should be treated before they become fully

symptomatic, when encasement of the innominate vein,SVC bifurcation is suspected, as a Y-shaped stricture istechnically more difcult to treat than a straight veinsegment. Multiple and bilateral stents might be requiredto treat the bifurcation and regional thrombolysis,preceding stent placement might be necessary to clearthe lumen from thrombosis before stenting. Patients inwhom nephrotoxic chemotherapy or other nephrotoxicdrugs are given and patients in whom extensivetumour lysis with hyperuricaemia, hypercalcaemia andemesis-related dehydration is expected may also benetfrom SVC desobstruction to increase tolerance of highvolume hydration, even if clinical symptoms of venousstasis are not prominent.

Relative contra-indications include preterminalpatients with malignant disease, extensive chronicvenous thrombosis, endoluminal tumour growth, andupper limb paralysis. Occlusion of the ostium of theazygos vein is not a contraindication. Mechanicalthrombectomy using rotational catheters or otherdevices should not be used in the SVC system, becauseof the risk of pulmonary embolism by a jugular veinthrombosis, that may become mobilized after successfulclearance of the downstream veins. Patients withsimultaneous tracheobronchial and mediastinal veinobstruction should undergo stenting of the airways rst.

Technique

Although SVC stenting is a straight forwardprocedure in simple cases, it can become extremelycomplex in cases with extensive obstruction. Phlebo-graphic demonstration by a bilateral arm injection ofcontrast medium is mandatory before treatment, tolocate the obstruction, appreciate its haemodynamicsignicance, extent of collateral venous drainage andany congenital variants and to allow planning of thestenting procedure (g. 13). In patients with severeoedema of the upper limbs, puncture of the axillary veinmay be targeted by a peripheral hand vein injection ofcarbon dioxide. In case of acute or subacute venous

thrombosis, local catheter directed thrombolysis maybe indicated, using an infusion of 70,000100,000 IUof urokinase per hour or another plasminogen acti-vator. Chronic occlusion is recanalized with catheter-guidewire techniques by a unilateral or bilateral axillaryvein or a femoral vein approach, or a combination of

both. Self-expandable and exible metal stents areplaced, when necessary, multiple and bilateral and inan overlapping position. Stent placement in the sub-clavian vein should be prohibited because of the riskof subclavian vein thrombosis or stent fragmentationby external clavicular compression. Stents in largeveins should be oversized by 2550% compared to thediameter of a fully dilated normal vein. PTA is notindicated prior to stenting in malignant disease, butshould be performed after stenting to establish opti-mal venous return immediately. In stenosis of benignorigin, PTA is indicated prior to stenting to probe thedegree of stenosis and for precise localization ofmaximum of resistance within the stenosed venous

segment. Perprocedure heparinization is advised in allcases [162, 163].

Results

Following successful restoration of ow in the SVCand innominate veins, complete or signicant relieffrom symptoms is obtained in 68100% of patients withmalignant disease [158164]. Delayed reinterventionduring the patient9s survival is only rarely required for afollow-up of 16 months. The type of bare metal stent isirrelevant to clinical results. Covered stents aregenerally not indicated, as endoluminal tumour extent

a) b)

c) d)

Fig. 13. A 36-yr-old female with mediastinal non-Hodgkinlymphoma, treated by chemotherapy. Prominent symptoms ofsuperior vena cava obstruction. a) Bilateral arm phlebographyshows obstruction of right and left innominate veins (arrows)and lateral thoracic collateral circulation (arrowheads). b)Venous recanalization was performed by a bilateral axillary veinapproach. Note recanalized and stented left innominate vein. c)and d) Phlebography shows normal ow in both innominateveins after bilateral stenting with 10 mm Wallstents.


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is an exceptional observation. The most prominentclinical symptoms are corrected within a few hours,face and neck oedema resolves in 12 days, and upperlimb oedema in 24 days. Benign SVC obstruction isobserved with increasing frequency in recent years.Generally patients with a benign stenosis present at themoment of treatment with extensive thrombosis due todelayed patient referral. Overall, similar results may beobtained in stenosis of malignant and benign origin,although a longer observation time in the benign groupallows for more delayed complications to occur.Haemodialysis related central venous stenoses areparticularly prone to formation of exuberant intimalhyperplasia within the stent or formation of stenosisin the adjacent venous segment. Repeated PTA orplacement of an additional stent may be requiredduring the rst years of follow-up. Stents should notbe placed in arm veins, as secondary obstruction is therule [162, 165168].

Complications

Complications of venous desobstruction are few.Local thrombolysis may lead to haemorrhagic com-plications. Stent related complications include mis-placement or migration, uncomplete stent opening,formation of de novo thrombosis, and pulmonaryembolism. Vein perforation, signicant infection,phrenic nerve decit by stent compression or puncturesite complications are rare.

Percutaneous vascular foreign body retrieval

Indications

Since its introduction, percutaneous catheter medi-

ated vascular foreign body retrieval has emerged as thetreatment of choice, avoiding thoracotomy and openheart surgery [12]. The growing clinical application ofintravascular devices in interventional radiologicalpractice has increased the risk for central venous em-bolization of many types of foreign materials besidesthe classical lost central venous lines, Swan-Ganzcatheters, ventriculo-atrial shunts, port-a-caths, cardiacstimulator lines and pacemaker electrodes. All intra-vascular embolized foreign bodies should be retrieved,as they are potentially associated with serious compli-cations according to their type and location. A 2171%long-term serious morbidity and a 25% death rate wasreported [169173]. Expected complications from a

foreign body that is partially or entirely blocked in theright heart are ventricular arrythmia, myocardialinfarction, myocarditis, recurrent pericardial effusion,tamponade and sepsis. Foreign bodies blocked in thepulmonary circulation may be responsible for throm-boembolism and sepsis. Relative contra-indications ofcatheter retrieval are free oating thrombus attached tothe foreign body and chronic incorporation of theforeign body in a thrombus or vessel wall.

Technique

Vascular foreign bodies are located with uoroscopyand, when necessary, phlebographic demonstration.

Extraction devices are relatively inexpensive and basedon the loop-snare technique, helical basket entrapmentor the grasping forceps technique or a combination ofthe above and other catheter-guide wire dislodgementtechniques (g. 14). The procedure is carried out underuoroscopic control and with local anaesthesia. Largeand uncompressible foreign bodies may require afemoral venotomy for extraction. Large stents retrievedfrom a pulmonary artery or from the heart can beabandoned in an iliac vein.

Results

The literature reports a success rate ofw90% by aclosed percutaneous retrieval [173]. The procedure mayfail, when no free ends of an endovascular line areavailable for snaring, when small catheter fragments arelodged too far in a small pulmonary artery branch orwhen small objects are incorporated in the wall ofcardiac chambers, or lodged in a thrombosed vein orhave perforated outside the venous wall. Failure ofpercutaneous extraction is obviated by early treatment,

a) b)

c) d)

Fig. 14. Percutaneous vascular foreign body retrieval. A 48-yr-old female. Stent placement in the right subclavian vein wasattempted in another hospital. The metal stent had migrated tothe left pulmonary artery. a) Pulmonary angiography shows a4 cm fully expanded metal stent (arrowheads), blocked in the leftinferior pulmonary artery. b) Foreign body retrieval was plannedwith a coaxial balloon extraction technique. The stent lumen wascatheterized with a guidewire allowing insertion of a percuta-neous transluminal angioplasty (PTA) catheter. c) Full inationof a PTA balloon inside the stent, allowed atraumatic stent re-traction in the iliac vein. d) The stent was abandoned in theright iliac vein, after balloon deation, avoiding right femoralvenotomy for extraction. Control phlebography shows optimalstent placement in the right iliac vein.


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without waiting for clinical symptoms to occur. Com-plications from percutaneous retrieval are rare inclu-ding transient arrythmia, further distal pulmonaryembolization of a friable foreign body and thrombosisat the puncture site.

Endoluminal tracheobronchial stenting

Indications

Tracheobronchial airway obstruction is a relativelycommon condition. Various therapeutic options areavailable and depend on the cause (benign versusmalignant), location (central versus peripheral) andorigin (intrinsic versus extrinsic) of the stenosis.Patient9s condition and the prognosis of disease arealso considered. Whenever possible, in malignantobstruction or in benign stenosis, surgery is the rstchoice [174]. With progress in technique, local treat-ment by bronchoscopy (laser, cryotherapy, electrocau-tery, photodynamic therapy, brachytherapy) has been

used with increasing frequency [175179]. Balloondilatation leads to a rapid improvement of therespiratory function after treatment of malignant andbenign bronchial stenosis, but relief of symptoms isoften short-lasting [180, 181]. Therefore, indication ofstents placement in the tracheobronchial tree hasincreased in frequency and can be placed underradiological or bronchoscopic control, or a combina-tion of both modalities [181, 182]. Compared tosurgery, stent insertion is a simple palliative method,resulting in immediate improvement in acute respira-tory distress from airway obstruction [181]. In non-surgical patients with malignant disease, indications oftracheobronchial stenting are: extrinsic compression or

submucosal disease; tracheo-oesophageal stula; andobstructive endobronchial tumour unresponsive toendobronchial treatment by debulging or resection,respectively [181190]. In benign stenosis, surgery maynot be indicated in patients with a short life expectancyor extensive airway stenoses. Stent insertion for benignstenosis has been reported in the following conditions:iatrogenic (postintubation or postanastomotic stric-ture); tracheobronchial malacia in children; extrinsiccompression from vascular structures or brosingmediastinitis; tracheobronchial infection (tuberculosis);and systemic disease (Wegener9s granulomatosis, relap-sing polychondritis and amyloidosis) [181, 182, 184,190196].

Technique

Precise measurements of the diameter of the trachealand bronchial lumen and location of the stenosiscompared to anatomical landmarks are performed withspiral CT before the procedure. Stents are insertedunder sedation or anaesthesia, following previousdilatation or laser ablation of the stenosis underuoroscopic and endoscopic control. Two types ofendobronchial stents are currently available in thetracheobronchial tree: silicone stents (Dumon,Dynamic, Reynders, and others) [181183, 186, 188,

190] and metallic stents, the latter including eitherballoon expandable stents (Palmaz and Strecker) orselfexpanding stents (Gianturco, Wallstent, Ultra ex)[181, 182, 187, 190, 192, 193, 197, 198]. Most metallicstents are available in covered and noncovered versions.No ideal stent is currently available. The type of stent tobe used is a matter of debate and is often dictated byavailability and individual preference. Most metallicstents can be inserted on an outpatient basis.

Results

Placement of stents leads to an immediate andsignicant decrease in symptoms and an improvementin respiratory function in 8095% of the patients. Mostof the patients with severe respiratory impairment areable to be discharged following treatment. As resultsdepend on optimal positioning of the prosthesis andsome of the stents show a poor visualization underuoroscopy, new advances in CT uoroscopy are

promising guiding techniques allowing precise and realtime control of stent insertion in selected cases.

Complications

Complications are related to the type of stent, andinclude early or late stent migration (119%), infection(322%), deformation or breakage (136%) and stentobstruction by secretions, granulation formation ortumour overgrowth (621%). Other complications,such as major haemorrhage and tracheobronchialstula are rare. New developments in stent congu-

ration and composition seem to be associated withan easier introduction and a lower rate of com-plications.

Conclusion

A close collaboration between interventional radi-ologists and pathologists, primary care physicians,pulmonologists, medical and radiation oncologists aswell as thoracic surgeons is a prerequisite for optimalpatient management, offering full therapeutic options.Future developments in imaging based patient manage-

ment mainly concern oncological applications. Follow-ing preliminary studies on percutaneous treatment ofinoperable or early non-small cell lung cancer, such aselectrochemical polarization of cancer [199], newmodalities are emerging including percutaneous bra-chytherapy [200] and radiofrequency tumour ablation[201]. Interventional radiology will also be used forcatheter or needle mediated immunomodulatory orgene therapy delivery to the target organs. Concerningstenting procedures, future types of stents includehybrid stents with metallic components and a smoothsynthetic covering of silicone or polyurethane, biode-gradable stents, chemically and radioactively coatedstents [182, 202].


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