intervencion usg emergencias

Radiol Clin N Am 42 (2004) 457–478

Emergent ultrasound interventions

Dean A. Nakamoto, MD*, John R. Haaga, MD

Department of Radiology, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA

Interventional radiologists are frequently asked to effusion. Ultrasound evaluation before the procedure

perform emergent diagnostic and therapeutic proce-

dures. The choice of image guidance depends on

user preference; availability of CT, ultrasound, and

MR imaging; and the ability of the modality to

visualize the target. Ultrasound is the most preferred

modality and has many advantages including real-time

imaging of the needle tip during the procedure; multi-

planar imaging capabilities; its relatively low cost; and

the equipment is mobile, so procedures can be per-

formed at the bedside of critically ill patients in the

intensive care unit. Ultrasound-guided interventions

have become very common in many institutions [1,2].

Emergent procedures frequently performed with ultra-

sound guidance include thoracentesis, paracentesis,

percutaneous nephrostomy, and percutaneous chole-

cystostomy. The role of ultrasound guidance has also

expanded to include abscess drainage, particularly in

the pelvis, and chest tube placement. This article

discusses various emergent interventions performed

with ultrasound imaging guidance.

Ultrasound-guided chest interventions

Thoracentesis

Ultrasound-guided thoracentesis is usually per-

formed easily because most pleural fluid collections

are accessible using percutaneous methods. In the

septic patient, a diagnostic thoracentesis is usually

performed to evaluate for empyema. Other indications

include evaluation for chylous, bloody, or malignant

0033-8389/04/$ – see front matter D 2004 Elsevier Inc. All right

doi:10.1016/j.rcl.2004.01.002

* Corresponding author.

E-mail address: [email protected]

(D.A. Nakamoto).

confirms the presence of fluid and distinguishes

pleural fluid from atelectasis, mass, or elevated dia-

phragm. Typically, the patient is seated upright. Pleu-

ral fluid is generally anechoic, although debris or

septations may be present. The diaphragm must be

identified, and the underlying liver or spleen. A 3- to

4-MHz sector or vector probe is usually sufficient to

survey the hemithorax quickly.

Technique

Most diagnostic and therapeutic thoracenteses are

performed with ultrasound guidance. Typically, the

patient is seated upright with his or her back to the

interventionalist. To perform the procedure safely,

there should be at least one rib interspace of fluid

above and below the puncture site. If there is less

fluid, the procedure may be deferred depending on the

clinical urgency and the ability of the patient to

cooperate. Very small pleural fluid collections can

be aspirated safely, however, if the patient can coop-

erate with breath-holding. Patients who cannot sit

upright are placed either supine or in a lateral decu-

bitus position. In either of the latter two positions,

there must be a larger amount of fluid to attempt

thoracentesis. Because ultrasound can be performed

portably, ultrasound-guided thoracenteses can be per-

formed in an ICU, even on mechanically ventilated

patients [3]. If visualization is difficult because of

patient body habitus, air in the pleural fluid, or the

patient’s inability to be positioned adequately, CT

guidance may be helpful.

Initial scanning should be performed with a sector,

vector, or curvilinear probe. This is to document the

amount of fluid and quickly to find the largest pocket

of fluid. At this time, it is important to verify the

location of the diaphragm. Scanning can then be

performed with a linear probe of 6 MHz. This enables

s reserved.

Fig. 1. Aberrant intercostal artery. This sagittal color Doppler

scan performed with a 6-MHz linear probe demonstrates an

aberrant, tortuous course of the intercostal artery (arrow).

Here the artery is situated close to the midpoint of the rib

interspace. In this location, the artery is more susceptible to

injury from a needle.

D.A. Nakamoto, J.R. Haaga / Radiol Clin N Am 42 (2004) 457–478458

accurate localization of the rib interspace, particularly

in obese patients. The location of the intercostal artery

(Fig. 1) also is verified at this time. Although the

artery is usually directly adjacent to the inferior aspect

of the rib, it can be located more inferiorly and in the

rib interspace. If the patient has a malignancy, pleural-

based metastases can also be visualized at this time

and avoided (Fig. 2). It is important to be able to

recognize hypoechoic, consolidated lung and not

mistake it for pleural fluid. Sometimes consolidated

Fig. 2. Pleural-based metastases. This patient with metastatic lung c

based mass was noted (cursors); a different location was used.

lung may mimic complex fluid (Fig. 3) and color

Doppler may be helpful to verify the presence of

pulmonary vessels in consolidated lung. Following

sterile preparation of the skin, local anesthesia should

be administered from the skin surface to the pleural

surface. Although one could use ultrasound to visual-

ize needle insertion directly, typically a site is marked

on the skin surface and the needle is advanced until

fluid is obtained.

A variety of needles and catheters are available for

thoracenteses. The simplest method is to use an 18- or

20-gauge angiocatheter. The angiocatheter with punc-

ture needle is advanced into the pleural space until

fluid is aspirated, and then the angiocatheter is ad-

vanced into the pleural space over the puncture

needle. Single-step 6F trocar-based catheters (Skater,

Medical Device Technologies, Gainesville, Florida)

are also available, particularly if the procedure is

both diagnostic and therapeutic. These are used in a

similar fashion.

After a thoracentesis, the authors obtain a chest

radiograph in posteroanterior view to evaluate for

pneumothorax. The chance of pneumothorax is small

and generally ranges from 2.5% to 7.5% [4–7],

although rates up to 13.9% have been reported [8].

Symptoms caused by pneumothorax include shortness

of breath and shoulder pain on the affected side. Some

investigators do not advocate routine postprocedure

chest radiograph for the asymptomatic patient, be-

cause of the low complication rate [4,9,10]; however,

because sizable pneumothoraces may be asymptom-

atic, the authors routinely obtain a chest radiograph.

The mechanisms of postthoracentesis pneumothorax

ancer was referred for therapeutic thoracentesis. The pleural-

Fig. 3. Consolidated lung mimicking complex pleural fluid. This patient was referred for possible thoracenteses. Longitudinal

vector scan of the left hemithorax demonstrates complex-appearing mixed solid and cystic foci in the hemithorax (arrowheads)

consistent with consolidation of the lung.

D.A. Nakamoto, J.R. Haaga / Radiol Clin N Am 42 (2004) 457–478 459

include (1) inadvertent introduction of air into the

pleural space, usually by leaving the needle or catheter

open to the air after the tip is in the pleural space;

(2) puncture of the lung; and (3) rupture of the vis-

ceral pleura because of a decrease in pleural pressure

[4,11]. If the pneumothorax is large, is symptomatic,

or increases with time, the patient may require a chest

tube placement.

Other significant complications of thoracentesis

include pain, vasovagal reaction, bleeding, and re-

expansion pulmonary edema. Pleuritic pain may be

caused by the rubbing of the visceral and parietal

pleural surfaces after the fluid has been removed. Pain

during the procedure may also be caused by the

inability of the patient’s collapsed lung to re-expand

as the fluid is removed. This may be an indication to

stop the procedure [4,7].

Vasovagal reactions may occur during any inter-

ventional procedure. The patient may become tran-

siently bradycardic, hypotensive, and may then lose

consciousness. Predisposing factors include volume

depletion. A quick physical examination of these pa-

tients shows bradycardia, diaphoresis, dilated pupils,

and hypotension. These vasovagal reactions are usu-

ally minor and temporary. Placing the patient in the

Trendelenburg position to improve venous return to

the heart usually resolves the problem. If the patient

improves within a few minutes, no other action is

needed. If significant, the patient may require atro-

pine. Typical atropine doses are as follows: adult—

1 mg intravenously; children—0.02 mg/kg to 0.60 mg

(maximum) intravenously. The treatment interval is

every 3 to 5 minutes to a total of 3 mg for adults or

2 mg for children. If the atropine does not improve the

situation, then urgent consultation with the resuscita-

tion team is appropriate.

Re-expansion pulmonary edema is an uncommon

complication of uncertain etiology. It may be asymp-

tomatic; however, it can cause various degrees of

hypoxia and can even be life-threatening [12,13]. It

presents as unilateral pulmonary edema, which may

progress to bilateral edema [4,12]. Re-expansion pul-

monary edema is believed to be more likely if a large

volume (ie, greater than 1 L) of pleural fluid is as-

pirated at one time. Some investigators have removed

up to 2 L at one time, however, without adverse con-

sequences [4,7].

Bleeding is an uncommon complication. The risk

is higher in patients with coagulopathies. It also may

occur with inadvertent laceration of the intercostal

artery [14]. The authors typically check platelets,

prothrombin time and partial thromboplastin time,

and International Normalized Ratio (INR) before

any procedure and adjust accordingly. They prefer

platelet counts over 50,000, and the prothrombin time

to be within 2 seconds of normal, or INR less than

1.5. Fine-needle aspirations may be performed out-

side of these ranges. Every case, however, should be

individually tailored.

Ultrasound-guided chest tube insertion

Pleural effusions can occur in a variety of settings,

including pneumonia (parapneumonic effusion); ma-

lignancy; bleeding; and fluid overload. The pleural

fluid can be classified as transudative or exudative,

depending on the laboratory analysis as described

in Box 1. Parapneumonic effusions are generally

Box 1. Light’s criteria for diagnosis ofexudative effusions

� Pleural fluid protein to serum proteinratio > 0.5

� Pleural fluid to serum L-lactatedehydrogenase ratio > 0.6

� Pleural L-lactate dehydrogenase con-centration more than two thirds ofthe normal upper limit for serumL-lactate dehydrogenase

*satisfying any one of these criteriasuggests exudative natureData from reference [16].


divided into complicated and uncomplicated effu-

sions. The uncomplicated effusions are transudative

effusions and small free-flowing exudative effusions.

These effusions can resolve spontaneously with anti-

biotic treatment.

The complicated effusions are exudative effusions

that do not respond to medical treatment and require

drainage. Empyema, hemothorax, and malignant effu-

sions are all complicated effusions. Indications for

drainage of pleural fluid are given in Box 2.

Regarding parapneumonic effusions, there are

three stages in the evolution of empyema [15,16].

The first stage is a free-flowing exudative effusion.

The second stage is the fibrinopurulent stage during

which the cellularity and protein content of the effu-

sion increase. Fibrin is deposited on the visceral and

parietal surfaces. The third stage is the organization

stage; fibroblasts and capillaries grow into exudates

and form a pleural peel. If untreated, this stage can

result in lung entrapment and subsequent fluid drain-

age into the chest wall or into the lung. Empyema

requires emergent drainage to control sepsis. The first

two stages should be drained by closed-tube drainage,

Box 2. Indications for drainage of pleuralfluid

� A very large pleural effusion causingcardiorespiratory embarrassment

� Grossly purulent or hemorrhagicpleural fluid

� Positive Gram stain� pH > 7.2� Glucose < 40 mg/dL� L-lactate dehydrogenase > 1000 U/L

either radiologic or surgical. The third stage usually

requires surgical decortication, although there are

some data suggesting that the pleural peels may re-

solve with closed-tube drainage [17].

Anechoic pleural collections or collections with

fine linear septations on ultrasound respond best to

catheter drainage, whereas those with a complex

honeycomb pattern usually fail catheter drainage and

require decortication. Patients showing parietal pleu-

ral thickness greater than 5 mm are unlikely to re-

spond to catheter drainage.

Indications for chest tubes and technique

The primary indication for chest tube placement is

to drain an empyema and prevent progression to the

organized stage. This can be accomplished with

surgical drainage or closed-tube drainage. Closed-

tube drainage can be performed with blind insertion

of a large-bore (22–34F catheter) chest tube placed by

a surgeon or with image-guided chest tube placement

using CT or ultrasound. Typically, smaller-bore, 8 to

14F catheters are used with the image-guided meth-

ods. The smaller tubes placed by imaging methods are

usually better tolerated by the patients than the larger,

surgically placed tubes. Therapeutic options for in-

fected pleural collections are summarized in Box 3.

Large pleural fluid collections are amenable to

single-step trocar catheters. The patient can be posi-

tioned either upright or in a lateral decubitus position

with the affected side up. As with a thoracentesis,

initial scanning should confirm the location of the

diaphragm and the overall size of the effusion. Once a

site is marked and the skin is sterilely prepared,

adequate local anesthesia should be used from the

skin surface to the pleural surface. A small incision

should be made with a scalpel, and the tract should be

dilated with a small hemostat. An initial aspiration

can be performed with a 19-gauge sheath needle with

a disposable 5F tetra-fluoro-ethylene (TFE) catheter

(Yueh centesis disposable catheter needle, Cook,

Box 3. Therapeutic options for infectedpleural collections

� Antibiotics� Tube thoracotomy� Intrapleural fibrinolytics (urokinase)� Thoracoscopy with lysisof adhesions

� Decortication� Open surgical drainage


Bloomington, Indiana) to determine the viscosity of

the fluid. A trocar–based, self-retaining catheter can

then be inserted blindly or under ultrasound visuali-

zation, depending on the size of the effusion. If the

effusion is thin, a single-step, 6 to 8F catheter (Skater,

Medical Technologies, Gainesville, Florida) can be

placed. Although 10F and larger catheters are avail-

Fig. 4. Complex left pleural effusion in heart transplant patien

demonstrates a large loculated left pleural effusion, which inve

illustrating the procedure. Under ultrasound guidance, a 19-gauge d

the effusion at the level of the midaxillary line. The needle is with

7.5-mm J 0.035-inch angiographic guidewire is placed. (C) The tra

self-retaining nephrostomy-type tube is placed. Arrows point to ne

able on single-step trocars, the authors have found

that these larger catheters can be difficult to insert in a

single-step procedure. If a 10F or larger catheter is

needed, the Seldinger technique can make catheter

insertion easier (Fig. 4). A standard 0.035-inch

angiographic guidewire can be placed through the

5F Yueh catheter and the tract can then be dilated.

t, left chest tube placement. (A) Longitudinal vector scan

rts the left hemidiaphragm. (B) Schematic representation

isposable sheath needle (Yueh centesis needle) is placed into

drawn, a small amount of fluid is aspirated, and a standard

ct is sequentially dilated to 10F catheter, and a 10F catheter

phrostomy tube.

Box 4. Indications for external drainage oflung abscess

� Persistent sepsis after 5 to 7 days ofantibiotic therapy

� Abscesses 4 cm or more in diameterthat are under tension

� Abscesses 4 cm or more in diameterthat are enlarging

� Failure to wean from a ventilatorbecause of a large abscess

Box 5. Relative contraindications forexternal drainage of lung abscess

� Noncompliant patient� Lack of an abscess-pleuralsymphysis

� Coagulopathy


CT is the preferred method for smaller effusions or

effusions close to vital structures, such as the heart or

major vessels. When placing the chest tube, a lateral

approach is preferred rather than a direct posterior

approach, if possible. The ideal site for catheter

placement is usually at the level of the midaxillary

line; the authors try to avoid a direct posterior

approach so that the patient does not lay on the tube.

Once the tube is placed, some of the fluid should

be withdrawn to confirm the location of the tube.

Direct visualization with ultrasound should also doc-

ument the location. The tube should be secured to the

skin and placed to a water-seal pleural drainage

system (Pleur-Evac, Deknatel, Fall River, Massachu-

setts) with suction at �20 cm H2O. Patients are

monitored daily to ensure proper tube functioning

and to record the amount of drained fluid. Once the

fluid becomes serous, the tube output has decreased to

20 mL or less per 24 hours, and the patient has

defervesced, the tube may be removed. A CT scan

should be performed before tube removal to ensure

that there are no undrained collections. Additional

drainage tubes may be placed for any separate collec-

tions not being drained.

Many empyemas are loculated, which can make

chest tube drainage difficult. Fibrinolytic agents, such

as streptokinase and urokinase, have been used suc-

cessfully to lyse septations [18–20]. Because uro-

kinase is not always available, the authors have been

using streptokinase, 125,000 IU every 12 hours for up

to 2 days.

Success rates range from 70% to 94%, with a

cumulative success rate of approximately 85% in

various radiologic studies [19–27]. Not all empyema

are amenable to percutaneous drainage. Patients who

develop a pleural peel or who have persistent fevers

and elevated white blood cell counts despite adequate

drainage and appropriate antibiotics may require sur-

gical drainage and decortication. Surgical treatment

for such patients should not be delayed. Complica-

tions from chest tube insertion include sepsis, inap-

propriate pathway of chest tube, bleeding, and injury

to adjacent organs.

Lung abscesses

Most lung abscesses are caused by oropharyngeal

aspiration of bacteria as can occur with alcoholic

stupor, general anesthesia, seizures, or cerebral vas-

cular accidents [28,29]. Other causes include malig-

nancy, septic emboli, foreign bodies, and lung cysts

[28,29]. It is important to distinguish between lung

abscess and empyema because empyema requires

external drainage, whereas most lung abscesses re-

solve with medical management [30]. The distinction

between lung abscess and empyema is best made with

contrast-enhanced CT. A lung abscess appears round

and if it contacts the pleural surface, it forms an acute

angle with the pleura. Empyema is more biconvex in

shape and forms obtuse angles with the pleura. The

wall of an abscess may have thick and irregular en-

hancement, whereas the enhancing pleura with empy-

ema has a smooth curvilinear appearance (ie, the split

pleura sign) [31].

Indications for external drainage of lung abscess

[32] are summarized in Box 4.

Relative contraindications for external drainage of

lung abscess are given in Box 5.

The abscess-pleural symphysis occurs when a lung

abscess is continuous with the pleura. It is important to

have a needle traverse the abscess-pleural symphy-

sis to decrease the chances of complications, such as

leak of abscess fluid into the pleural space and bron-

chopleural fistula. Catheter drainage is usually per-

formed by CT; however, ultrasound can be used in

selected cases. If the abscess-pleural symphysis is

small, CT is the modality of choice because it is easier

to place the needle accurately under CT guidance.

Because lung abscesses may have fine strands of

residual normal parenchyma, which can bleed, one

should not be too aggressive with catheter insertions or

guidewire manipulations [32].


Ultrasound-guided abdominal interventions

Paracentesis

Ultrasound-guided paracentesis is a commonly

performed procedure. Typically, the procedure is per-

formed emergently in a septic patient as a diagnostic

procedure to evaluate for spontaneous bacterial peri-

tonitis [33] or for hemoperitoneum in the setting of

trauma [34]. More commonly, this procedure is per-

formed urgently as a therapeutic measure for symp-

tomatic relief of tense ascites.

Initial scanning is performed with a sector or cur-

vilinear probe to find the largest pocket. Attention is

then made to the abdominal wall to ensure that there

are no vessels at the site of subsequent needle punc-

ture, such as the epigastric artery or collateral vessels

in a patient with cirrhosis. In patients with malignan-

cy, one should ensure that there are no peritoneal

metastases at the needle insertion site. This can be

performed with a linear transducer, usually of 6 MHz

or greater. The preferred site for large-volume para-

centesis is chosen in the dependent position, such as

right or left lower quadrants. The site of puncture is

chosen usually lateral to the rectus muscle to avoid the

accidental puncture of the inferior epigastric artery.

The inferior epigastric artery normally travels at the

junction of the medial two thirds and lateral one third

of the rectus or approximately 5 cm laterally from the

midline (Fig. 5). After standard sterile skin prepara-

tion, 1% lidocaine is injected into the abdominal wall

for local anesthesia. The authors anesthetize all the

Fig. 5. Paracentesis, epigastric artery. (A) Color Doppler transvers

transducer was used to localize the location of the inferior epiga

location along the lateral aspect of the rectus abdominis muscle. (B

the epigastric arteries (arrowheads).

way to the parietal peritoneum. Then they perform the

aspiration with a standard 18-gauge angiocatheter. If

the patient is obese, the authors use a 15- or 20-cm-

long, 19-gauge sheath needle (Yueh centesis dispos-

able catheter needle; Cook, Bloomington, Indiana).

For smaller collections or collections adjacent to ma-

jor vessels or to the spleen, the authors use direct

ultrasound guidance with either the freehand tech-

nique or the needle guide.

Large-volume paracentesis provides rapid resolu-

tion of symptoms with minimal complications and is

well tolerated by most patients. Complications from

paracentesis have rarely been reported, and include

inferior epigastric artery pseudoaneurysm [35], hem-

orrhage after large-volume paracentesis [36–38],

bowel perforation [38], hypotension [39], and a frag-

ment of the catheter left in the abdominal wall or

peritoneum [38]. Postparacentesis circulatory dys-

function has been reported and is characterized by

hyponatremia, azotemia, and an increase in plasma

renin activity. Postparacentesis circulatory dysfunc-

tion is associated with an increased mortality and may

be prevented by administration of albumin intrave-

nously (6 to 8 g/L of ascites removed) along with large

volume parasynthesis (LVP).

Percutaneous cholecystostomy

Acute cholecystitis in high-risk patients in the

ICU is difficult to manage. In critically ill, oftentimes

septic patients with possible acalculous or gangrenous

cholecystitis, percutaneous cholecystostomy may be

e image of the anterior abdominal wall with a 6-MHz linear

stric artery (arrow) before paracentesis. This is the typical

) CT scan on a different patient demonstrates the location of


both diagnostic and therapeutic. These patients are not

suitable candidates for surgery. Percutaneous chole-

cystostomy is used as a diagnostic and therapeutic

procedure in these critically ill and difficult to manage

patients [26,40–43]. In unstable patients with calcu-

lous cholecystitis, percutaneous cholecystostomy per-

mits stabilization so that cholecystectomy can be

performed electively.

Indications

Percutaneous cholecystostomy may be performed

in critically ill septic patients to exclude acute cho-

lecystitis, because of the difficulties of establishing

the diagnosis of acute cholecystitis in these patients

[26,44,45]. The findings on the various diagnostic

tests can be nonspecific. A sonographically normal

gallbladder virtually excludes cholecystitis in an ICU

patient, and a positive sonographic Murphy’s sign

may be the most specific finding of acute cholecystitis

in these patients [46]. Other findings, such as sludge,

distention, pericholecystic fluid, wall thickening, and

striations, are nonspecific in this setting [46,47]. The

presence of gallstones, distention, and pericholecystic

fluid, however, have been described as findings that

may predict a more favorable response to percutane-

ous cholecystostomy [41,47]

Technique

Two access routes are used. The transhepatic route

approaches from the right midaxillary line and aims

for the ‘‘bare’’ area of the gallbladder. This route is

preferred by most investigators and theoretically

reduces the risk of bile peritonitis [26,41,42,48]. The

transperitoneal approach is from the anterior abdomen

and is aimed at the gallbladder fundus [41,49–51].

Because of the risks of bile peritonitis and inadvertent

perforation of the colon, the transperitoneal approach

is probably best reserved for patients with very dis-

tended gallbladder in which the gallbladder fundus

abuts the anterior abdominal wall. This approach is

also useful in patients with coagulopathy or underly-

ing liver disease [41,43,49–51]. The transhepatic

route for percutaneous cholecystostomy does not al-

ways result in a puncture of the ‘‘bare area’’ of the

gallbladder and the ‘‘free’’ peritoneal surface of the

gallbladder may still be punctured [52]. Some inves-

tigators have also used simple aspiration of the gall-

bladder contents without placement of a drainage tube

[45,53]. The authors typically use the transhepatic

approach and ultrasound guidance. Sometimes CT

guidance may be necessary, however, particularly

for a liver in a high subcostal location. Typically, a

small 6F single-step trocar catheter (Skater, Medical

Device Technologies, Gainesville, Florida) is used. If

the trocar-based catheter buckles against the liver or

gallbladder wall, the Seldinger technique can be used

(Fig. 6). The acutely inflamed gallbladder wall can be

friable and catheter and wire manipulations should not

be too aggressive. If the Seldinger technique is used,

the authors use a 5F catheter on a 19-gauge needle

(Yueh centesis disposable catheter needle, Cook,

Bloomington, Indiana) to puncture the gallbladder

lumen. They then use a standard 0.035-inch guide-

wire; carefully dilate the tract to 8F catheter; and then

place an 8F catheter, self-retaining nephrostomy tube.

The authors recommend not using a super-stiff guide-

wire, such as an Amplatz, because it may perforate the

gallbladder wall. If the transperitoneal approach is

used, a small 8F catheter or less, single-step trocar

catheter is recommended. The gallbladder lumen

should be punctured with a sharp jab, and the gall-

bladder should be emptied once the catheter is within

[49]. The Seldinger technique is not favored with this

technique, because there is a theoretical risk of bile

leakage into the peritoneum.

Once the self-retaining tube is within the gallblad-

der, it is recommended that it remain there for at least

2 to 3 weeks to allow formation of a mature tract along

the catheter; otherwise, there may be bile leakage once

the catheter is removed [42,48]. It also is recom-

mended that a cholangiogram be performed before

catheter removal to ensure patency of the cystic duct

and common bile duct [26,48,54]. Some investigators

also advise imaging the tract at the time of tube

removal [26,43,44], although other investigators dis-

agree [41,49] even if the transperitoneal approach is

used [49].

Complication rates generally range from 5% to

13.8% [41,43,45,49,51,55]. Complications include

bleeding, bile leakage, catheter dislodgement, and

vasovagal events. Bile leakage has been reported with

both the transhepatic and transperitoneal approaches.

Technical success rates (ie, adequate placement of a

drain in the gallbladder) are high (ie, as great as 97%–

100%) [26,41–43,45,47–49,56]. Overall patient re-

sponse is lower, however, because of the relatively

low threshold of clinicians to request the procedure

and the nonspecificity of the diagnostic tests; no

clinical response to the procedure can be found in up

to 42% of the patients [26,42]. Placement of a chole-

cystostomy tube is still helpful in these circumstances,

however, because it does reassure the clinicians that

cholecystitis is not a cause of a patient’s sepsis.

Some investigators have used simple gallbladder

aspiration in patients with suspected acute cholecys-

titis [45,53]. Simple percutaneous gallbladder aspira-

tion does seem to be beneficial in patients with acute

cholecystitis and comorbid conditions. Chopra’s et al

Fig. 6. Ultrasound-guided percutaneous cholecystostomy in a patient status-post recent myocardial infarction. (A) Longitudinal

vector scan demonstrates distended gallbladder with sludge and a thick wall. Initial attempts with a 6F catheter one-step trocar-

based catheter were not successful, because of the thickened gallbladder wall. The catheter buckled on the trocar. The Seldinger

technique was used. A 19-gauge disposable sheath needle (Yueh centesis needle) was used to enter the gallbladder lumen. A

standard 0.035-inch angiographic guidewire was placed, the tract was carefully dilated to 8F catheter, and a self-retaining 8F

catheter nephrostomy-type tube (arrowhead) was placed. (B) Schematic representation of the procedure described in Fig. 6A.


[45] patient population, although at high surgical risk,

consisted of noncritically ill patients. As stated in their

article, they excluded patients who had had prolonged

admission to the ICU.

Intra-abdominal abscess drainage

Image-guided percutaneous abscess drainage is a

well-established technique, which has become the

primary method of treatment for many patients with

intra-abdominal abscess [18,57–60]. In many hospi-

tals in the United States, CT is the imaging modality of

choice to detect abscesses. Once detected, an abscess

can be drained using either CT or ultrasound guidance

depending on which modality best delineates the

abscess and its surrounding structures. In general,

CT is used for abscesses inaccessible to ultrasound,

such as abscesses in deep locations adjacent to vital


structures (eg, major vessels or those adjacent to

bone), which may block the ultrasound beam. These

abscesses include pancreatic, interloop, and deep

retroperitoneal abscesses. Abscesses in more superfi-

cial locations of the peritoneum or visceral organs are

usually amenable to ultrasound guidance. Ultrasound

has many advantages, including its lower cost, its

ability to be performed portably at the patient’s bed-

side, and its multiplanar imaging capabilities.

Indications

In general, intraperitoneal abscesses adjacent to the

abdominal wall and abscesses in the periphery of

visceral organs, such as the liver or kidney, are

amenable to ultrasound-guided aspiration and drain-

age. The authors always avoid traversing uninvolved

spaces or organs, such as the liver or bowel, when

performing any interventional procedure. The excep-

tions are traversing the stomach for pancreatic proce-

dures and traversing the rectum or vagina for pelvic

abscess drainages. Other investigators have reported

success without significant complications from tra-

versing uninvolved spaces or organs while performing

interventional procedures [61–63]. If a loop of bowel

is inadvertently traversed with a catheter, the catheter

should be left in place for 2 to 3 weeks so a tract can

form. After this period the catheter can usually be

removed safely without spillage of bowel contents

into the peritoneum [64,65]. This assumes that the

underlying bowel is otherwise normal and that there is

no distal bowel obstruction. Relative contraindica-

tions common to all percutaneous procedures include

coagulopathy, the patient’s inability to cooperate, and

lack of safe access to the abscess.

Technique

Simple, uncomplicated abscess drainage is de-

scribed next.Management of more complex abscesses,

such as infected hematomas, abscesses associated

with fistulae, and fungal abscesses, is also discussed.

Pelvic abscesses, particularly those caused by gyne-

cologic sources, are discussed separately.

Preprocedure imaging is best performed with CT

because the size of the fluid collection, its location,

and extent can be well-delineated. The authors typi-

cally review the patient’s CT before the procedure and

if possible have a copy of the CT in the ultrasound

suite when performing the procedure. The CT pro-

vides an excellent roadmap to help plan the needle

trajectory. The authors frequently use a commercially

available needle guide, although for superficial ab-

scesses they use the freehand technique. For most

abscesses, the Seldinger technique is favored unless

the abscess is very large and superficial.

After obtaining informed consent, the fluid is

localized and the needle trajectory planned. The site

for needle insertion is marked, and the skin is prepared

and draped in a sterile manner. The ultrasound probe

is then covered with a sterile cover, and the needle

guide is attached unless the procedure is performed

freehand. A skin wheal is raised with local 1% lido-

caine, and a skin nick is made with a scalpel. Using a

19-gauge sheath needle (Yueh centesis disposable

catheter needle; Cook, Bloomington, Indiana), the

projected needle tract is anesthetized to the fluid

collection. The fluid collection is then punctured with

the 19-gauge sheath needle, the 5F disposable sheath

catheter is advanced over the needle, the sharp needle

is then removed, and the fluid is aspirated through the

5F disposable catheter sheath. If the fluid is purulent, a

standard 0.035-inch angiographic guidewire can be

advanced into the abscess. After confirming the loca-

tion of the guidewire, the tract can be dilated and an

appropriate-sized, self-retaining nephrostomy tube

can be placed. For thin pus, 8 to 10F catheters are

usually sufficient. Catheters up to 14F can be used for

more viscous pus. The tube position should then be

verified so that additional purulent fluid can be

aspirated. The catheter is then secured to the skin

either with sutures or adhesive fixation devices

(Percu-Stay Percutaneous Catheter Fastener, Derma

Sciences, Princeton, New Jersey).

Routine catheter care is then performed. The

authors place catheters to gravity drainage. Daily tube

rounds are made to evaluate the drainage progress.

Once the fluid becomes serous, the tube output has

decreased to less than 20 mL per 24 hours, the patient

has defervesced, and the white blood cell count is

normal, the tube may be removed. The authors typi-

cally repeat a CT scan before tube removal to ensure

that there are no residual fluid collections.

Liver abscess

Pyogenic liver abscesses located in the periphery

are amenable to ultrasound aspiration and drainage.

Those located more centrally are better approached

with CT guidance. Typically, a cuff of normal paren-

chyma should be included within the needle trajec-

tory to prevent spillage of the abscess contents into

the peritoneum (Fig. 7). The pleural space, loops

of bowel, and large intrahepatic vessels should be

avoided. Multilocular abscesses may be drained;

however, close follow-up and additional catheters

may be necessary [62]. The cure rate for liver abscess

Fig. 7. Ultrasound-guided liver abscess drainage in a septic patient whose previous catheter was inadvertently pulled out. (A) CT

scan demonstrates residual abscess in the dome of the right lobe of the liver (arrows). (B) Transverse ultrasound of the liver

demonstrates the 8F pigtail catheter (arrowhead) placed by the Seldinger technique into the abscess by a subphrenic approach.


is about 80% to 90%. Causes of failures of percuta-

neous drainage of liver abscess are given in Box 6.

Renal and perinephric abscess

Renal and perirenal abscesses may be drained

using ultrasound guidance; however, such abscesses

are usually better detected and delineated by CT [66].

This is particularly important for abscesses in the

pararenal space because they can extend from the

pelvis to the diaphragm. A posterolateral approach is

preferred because it avoids the erector spinal muscles,

colon, liver, and spleen.

Percutaneous nephrostomy

The main emergent indication for percutaneous

nephrostomy is pyohydronephrosis, which can occur

in native or a transplant kidney. Other urgent indica-

tions include a rapidly rising creatinine level or recent

endourologic complication. Indications of percutane-

ous nephrostomy are summarized in Box 7. Ultra-

sound is an excellent method to guide the initial

needle placement for percutaneous nephrostomy.

These procedures are typically performed in the

angiography suite using a portable ultrasound unit.

Although the entire procedure can be performed

with fluoroscopic guidance only, ultrasound is very

Box 6. Causes of failures of percutaneousdrainage of liver abscess

Preprocedure

Unable to access the abscess safelyImproper pathway to abscessInability to place the catheter appropri-

ately within the abscess

Postprocedure

Premature withdrawal of catheterDislodged catheterCatheter kinked or occludedHigh-output fistula to gastrointesti-

nal tractFungal abscessInfected necrotic tumorViscous pus or multiple septations,

resistant to fibrinolytic therapySepsis or death

Box 7. Indications for percutaneousnephrostomy

1. Relief of urinary obstructionImprove renal functionEvacuate pyonephrosisAssess recoverable renal function in

chronic obstruction2. Diversion of urine in case of urinary

leakageTraumatic or iatrogenic urinary

tract injuryInflammatory or malignant

urinary fistula3. Provide access for urinary

manipulationPerform dynamic flow-pressure

studies (Whitaker test)BiopsyStone therapyBenign stricture dilatationUreteral stent placementForeign body retrievalNephroscopic surgery

(eg, endopyelotomy)Administration of antifungal agents


useful for obtaining initial access to the renal collect-

ing system [20,67], particularly in cases where the

hydronephrosis is mild, or for renal transplants where

the renal axis can vary. For a native kidney, the

authors target a posterior calyx using a posterolateral

approach to avoid most of the erector spinus muscles.

For transplant kidneys, the authors target an anterior

calyx. Typically, they use a 20-gauge Chiba needle for

initial access, followed by instillation of contrast and a

small amount of air (3–5 mL) to confirm the needle

position (Fig. 8). The air rises to the nondependent

calices. If the needle position is satisfactory, the tract

can be dilated with a micropuncture set through the

20-gauge Chiba needle. If there is a better site to

access the collecting system, a second needle can then

be placed under fluoroscopic guidance using either a

20-gauge Chiba needle or 19-gauge sheath needle

(Yueh centesis needle). The tract is dilated using the

Seldinger technique, and an 8 to 14F catheter self-

retaining nephrostomy tube can be placed.

Splenic abscess

Splenic abscess if untreated have a mortality rate

of 80% to 100% and mortality rate of 14% to 30%

with surgical drainage. Experience with percutaneous

drainage is limited [59,68–70]. Although no major

complications were reported in these series [59,70],

their numbers were small. Green [68] described suc-

cessful percutaneous drainage in only one of four

patients. Lucey et al [67] successfully drained five

of six splenic abscesses; the one failure required a

splenectomy. The authors believe that splenic abscess

drainage should only be performed in rare circum-

stances and should generally be reserved for select

patients. Close consultation with the surgical service

is recommended so that an emergent splenectomy can

be performed if needed. If percutaneous drainage of a

splenic abscess is to be attempted, the abscess ideally

should be peripheral so that the least amount of nor-

mal splenic parenchyma is traversed. Thanos et al

[69], however, have performed drainages in two pa-

tients where the needle and catheter traversed 2.3 cm

of normal splenic parenchyma.

Fistulae

Uncomplicated abscesses have gradually decreas-

ing output following percutaneous drainage. In those

abscesses with persistently elevated output (ie, greater

than 100 mL per 24 hours) more than 3 to 4 days after

Fig. 8. Ultrasound-guided percutaneous nephrostomy in a renal transplant with pyohydronephrosis caused by ureteral calculus.

(A) Initial ultrasound demonstrates complex-appearing urine within the hydronephrotic transplant, which is consistent with

pyohydronephrosis. The indwelling stent is noted (arrows). (B) Longitudinal ultrasound of the dilated distal transplant ureter

demonstrates an obstructing calculus in the cursors. Note the ‘‘twinkle’’ artifact from the calculus with the color Doppler.

(C) Longitudinal image during placement of a nephrostomy tube (arrowhead). (D) Schematic representation of the kidney and

positioning of the catheter.


Fig. 8 (continued ).


initial catheter placement, especially drainage consist-

ing of bilious or enteric material, a gastrointestinal

fistula is likely [71,72]. At this point a sinogram con-

firms the communication to the gastrointestinal tract.

The cause of the fistula should then be determined so

that appropriate treatment may be initiated. Fistulae

caused by distal obstruction, neoplastic involvement,

or ongoing infection must have these underlying

conditions corrected or the abscess does not heal.

Low-output fistulae (ie, less than 320 mL per day)

usually close spontaneously without additional thera-

py [18]. High-output fistulae may require additional

treatment, including suction on the abscess catheter,

and bowel rest often with nasogastric tube placement.

Hyperalimentation may be necessary, and surgical

intervention may be required [18].

Infected hematomas

Most infected hematomas do not drain with simple

catheter placement because of their extensive amount

of fibrin and the protective effects of fibrin on bacteria

[18]. For patients with a suspected infected hema-

toma, the authors perform an initial aspiration. If

the fluid is bloody but not grossly infected, they only

take a sample for laboratory analysis and do not place

a catheter for the fear of secondary infection. If

the fluid is grossly purulent or if the cultures subse-

quently come back positive for infection, a drainage

catheter is placed. Sometimes local instillation of fi-

brinolytic agents, such as streptokinase, 125,000 IU

twice a day-for 2 days, may improve drainage from

such hematomas.

Fungal abscess

Fungal abscesses are difficult to treat with percu-

taneous drainage and may require surgical drainage

and debridement [18,73]. This is probably caused by

the extensive tissue invasion, necrosis, and mycotic

plaque formation in the wall of the cavity [18].

Echinococcal abscess

A number of investigators have described success-

ful treatment of hydatid cysts using percutaneous

aspiration and drainage [74–79]. The technique is

similar to routine abscess aspiration and drainage.

Various catheter irrigants are used, such as hyperto-

nic saline [74,79], scolicidal agent [75], or alcohol

[76,77,79]. Anaphylaxis is a potential complication,

which can be severe or even fatal [78]. Many of the

patients were given prophylaxis with albendazole.

Some investigators perform single-step aspiration

[74,77], whereas others aspirate the smaller cysts

and leave catheters in larger (> 6 cm) cysts [75,78,79].

Pelvic abscesses

Image-guided percutaneous drainage (Fig. 9) is

commonly performed for pelvic abscesses. Typically,

pelvic abscesses arise from gastrointestinal sources,

such as diverticulitis, ruptured appendicitis, and

Crohn’s disease, and from postoperative fluid collec-

tions. In female patients, pelvic abscesses may also

arise from gynecologic sources, such as tubo-ovarian

abscess from pelvic inflammatory disease. Such pel-

vic abscesses are traditionally treated with medical

therapy and if drainage of abscess is required many

investigators prefer image-guided interventional tech-

niques [80–87]. Pelvic abscesses in a female second-

ary to gynecologic causes are a special category and

usually have acute presentation.

Imaging-guided pelvic abscess drainage offers

several advantages to traditional surgical drainage.

The imaging-directed methods are less invasive and

do not require general anesthesia. The indications for

surgical drainage include ruptured tubo-ovarian ab-

scess, when diagnosis is uncertain; pelvic abscess

secondary to appendicitis or ruptured viscus [88];

and failed percutaneous drainage. The imaging-guid-

ed methods include transabdominal, transgluteal,

transrectal, and transvaginal approaches. The trans-

perineal approach has also been described [89]. In

general, the transabdominal approach is preferred,

Fig. 9. Ultrasound-guided pelvic abscess drainage, transabdominal, in a postsurgical patient. (A) Initial CT scan demonstrates

abscesses in the right and left lower quadrants of the pelvis (arrows). (B) Under ultrasound guidance the abscess in the right

lower quadrant was localized and punctured with a 19-gauge sheath needle. After confirming pus, a standard 0.035-inch

angiographic guidewire (Rosen) was advanced into the abscess. The tract was dilated to 10F catheter, and a self-retaining 10F

catheter nephrostomy tube (arrowhead) was placed. (C) The left lower quadrant abscess was then localized. Initial attempts were

made with a 12F one-step catheter; however, the patient complained of too much discomfort. This abscess was also punctured

with a 19-gauge sheath needle. After confirming pus, the tract was dilated and a 12F catheter nephrostomy tube was placed

(arrowhead). (D) Schematic representation of the procedure.


Fig. 9 (continued ).


using CT or ultrasound, because it is very well-

tolerated by patients. Pelvic abscesses may not be

accessible using the transabdominal approach, how-

ever, because of the presence of intervening loops of

bowel, urinary bladder, major blood vessels, or the

uterus. The transgluteal approach has several disad-

vantages, including patient discomfort, injury to the

sciatic nerve, and an increased chance of catheter

kinking and subsequent malfunction [84,90]. Al-

though initially underused, some investigators have

recently been successful using the transgluteal ap-

proach [90–93]. The transrectal [94–97] and trans-

vaginal approaches are well established [60,80–

84,88,98]. The transrectal approach can be guided

using CT [94], ultrasound [95–97,99], or ultrasound

combined with fluoroscopy [100]. The transvaginal

approach is usually guided with ultrasound.

Most patients with tubo-ovarian abscesses respond

to intravenous antibiotic therapy. As expected, the

response to antibiotics is inversely related to the size

of the abscess [82]. In unruptured tubo-ovarian ab-

scesses not responding to antibiotics, image-guided

drainage is indicated. The decision to proceed with

drainage is usually made in conjunction with the

gynecologic service. The authors prefer the trans-

abdominal approach, if possible, followed by the

transrectal approach with CT guidance, and finally

the transvaginal approach with ultrasound. Female

patients tolerate transrectal catheter placement better

as compared with transvaginal placement [99]. The

authors use the transgluteal approach only when

necessary (ie, a deep pelvic abscess in a patient with

underlying rectal mucosal disease or in premenarchal

or sexually inactive females). The transperineal ap-

proach provides an additional option for deep pelvic

abscess drainage and may be a viable alternative for

patients who have undergone abdominoperineal re-

section [89].

Technique

The transvaginal approach is best performed with

ultrasound guidance (Fig. 10). First, the abscess

should be localized by endovaginal ultrasound. The

abscess should be directly adjacent to the vaginal

vault with no intervening structures. The ultrasound

probe then is removed and the perineum and vagina

are prepared with a standard povidone-iodine solu-

tion. A vaginal speculum is then inserted and the

vaginal vault is prepared using sponges soaked in io-

dine-iodine solution. The speculum is then removed.

Despite the iodine-iodine preparation, the vagina is

still semi-sterile. If the patient is not already receiving

intravenous antibiotics, she should be given an appro-

priate antibiotic before beginning the procedure. Be-

cause it can be difficult to hold the ultrasound probe

while doing the various catheter manipulations, the

procedure generally requires two people.

The endovaginal ultrasound probe is then fitted

with a modified guide to allow catheter insertion. The

commercially available needle guides typically do not

allow placement of trocar-based catheters. Various

methods can be used [80,88], although the authors

prefer using the plastic sheath that comes with the

catheter, as described by O’Neill et al [79]. The

endovaginal probe is initially placed in a sterile probe

cover with coupling gel. A modified guide then is

made from the plastic catheter protector. The plastic

protector is cut so that approximately 5 cm of the

catheter protrudes beyond the end of the guide; a slit is

then made along the length of the guide, which

facilitates subsequent removal of the guide from the

catheter. This modified guide is then attached to the

sterilely prepared endovaginal probe with sterile rub-

ber bands along the groove intended for the metal

probe guide. The 6 to 8F trocar-based catheter (Skater,

Medical Device Technologies, Gainesville, Florida) is

then placed into the modified guide and a second

sterile probe cover is placed over the catheter and

guide. The catheter punctures the outer sterile probe

cover before puncturing the vaginal wall. One can

attempt to use local lidocaine at the vaginal wall but

this can be difficult because there are no landmarks to

ensure that the same area is traversed with the catheter.

Before placing a catheter, an initial aspiration should

be performed using an 18- to 20-gauge needle to

document infection. Initial scanning should be done

to place the abscess centrally within the scan plane

and to visualize where the catheter enters the abscess.

The tip of the trocar-based catheter should indent the

Fig. 10. Ultrasound-guided transvaginal pelvic abscess drainage. (A) Photograph shows the trocar catheter advanced through the

guide and projecting approximately 5 cm past the end of the probe (arrow). Note that the guide (plastic sheath) needs to be cut to

a length such that it allows at least 5 cm of catheter advancement so that the catheter can be advanced through the vaginal vault.

(B) Photograph shows the catheter has been fed off and the pigtail has been formed. The inner needle has been removed, but the

outer metal cannula stiffener is left in the straight portion of the catheter to stiffen it and ease the peeling away of the guide from

the catheter. (C) CT scan shows a complex right adnexal fluid collection (straight arrow). An incidentally noted right-sided

fundal fibroid is noted (curved arrow). (D) Transvaginal ultrasound scan shows trocar-catheter assembly (arrow) in the right

adnexal collection along the guide. (From O’Neill MJ, Rafferty EA, Lee SI, et al. Transvaginal interventional procedures:

aspiration, biopsy, and catheter drainage. Radiographics 2001;21:657–72; with permission.)


wall of the abscess during light palpation. Assuming

there are no intervening structures and the trajectory is

appropriate, the abscess wall is punctured using a

sharp thrust of 1 to 2 cm. This is the most difficult part

of the procedure. It is helpful to apply enough pressure

with the endovaginal ultrasound probe so that the

vaginal wall is taut before being punctured with the

trocar. The sharp needle of the trocar is removed and a

diagnostic aspiration is performed. Once pus is aspi-

rated, the catheter is advanced over the metal stiffener

of the trocar until the self-retaining loop is formed and

locked. The endovaginal probe is then removed care-

fully and the rubber bands and outer sterile cover

gradually are cut. The modified guide is then removed

from the catheter. This is easier to perform if the metal

stiffener is placed partially within the catheter. The

stiffener is then removed and more pus is aspirated.

Because of difficulties in penetrating the vaginal wall,

the authors have found that 10F or smaller catheters

are easier to insert.

Although the single-step trocar-based catheter is in

general easier to perform, the authors find the Sel-

dinger technique useful for inserting larger catheters

into abscesses with thick pus [84,101,102]. For expe-

rienced operators, ultrasound alone can be used.

Alternatively, a combination of ultrasound and fluo-

roscopy can be performed. With the Seldinger tech-

nique, the abscess is punctured with a 19-gauge sheath


needle with a disposable 5F TFE catheter (Yueh

centesis disposable catheter needle; Cook, Blooming-

ton, Inidana). After aspirating pus to confirm its

location, the 19-gauge needle is removed, leaving

the 5F catheter in the abscess, and a standard 0.035-

inch angiographic guidewire is advanced into the

abscess. The 5F TFE catheter is then removed and a

standard 5F pigtail catheter is placed over the guide-

wire and coiled into the abscess. Placement should be

confirmed with ultrasound. The disposable 5F TFE

catheter is not long enough to allow a guidewire to

coil within the abscess. The 0.035-inch guidewire is

removed, and a 0.035-inch Amplatz wire (Amplatz

Super Stiff, Boston Scientific, Medi-Tech, Miami,

Florida) is advanced into the 5F pigtail catheter. The

5F pigtail catheter is then removed, the tract can be

dilated up to 14F catheter, and an appropriate size of

self-retaining nephrostomy-type tube can be placed. If

the abscess is large enough, an Amplatz wire can be

introduced initially; however, this must be done care-

fully to avoid perforating the wall of the abscess with

the super-stiff wire. The stiffness of the Amplatz wire

(Amplatz Super Stiff, Boston Scientific, Medi-Tech,

Miami, Florida) allows the tract to be dilated despite

the distance between the operator’s hands and the

point of wire insertion in the vaginal wall. Less stiff

guidewires may kink. All of the dilatations can be

performed through the modified guide on the endo-

vaginal probe.

Some investigators perform simple needle aspi-

ration of an abscess without catheter placement

[81,103–106]. Although large, multiloculated collec-

tions can be treated this way, this method may be most

useful for small, unilocular collections. Nelson et al

[80] found no correlation between the size of an

abscess and the success rates for simple aspiration.

The advantages of this method are that it is safe, easier

to perform than catheter drainage, and there is no

problem with catheter misplacement or dislodging.

The disadvantages include multiple punctures for

multiloculated abscesses, an extended period of anti-

biotic coverage to control residual infection, and re-

peat aspiration for recurrent abscess [81,88]. For this

method, a standard needle guide attached to an endo-

vaginal probe can be used with an 18- to 20-gauge

needle. The needle must be at least 18 to 20 cm long to

fit through the needle guide. Contraindications in-

clude diffuse multifocal abscesses or abscess with

peritonitis, abscesses associated with fistulas, foreign

bodies, or abscesses caused by pancreatitis.

After the catheter is placed in the abscess and

locked in position, the authors tape the catheter to the

patient’s leg. Routine catheter care is then used. The

catheters are left to gravity drainage. The authors do

not routinely flush the catheters unless they are using

fibrinolytic agents, such as streptokinase.

Success rates for transvaginal drainage range from

78% to 100% [60,81,82,84,98,106]. Similar success

rates are noted for the other methods (ie, transabdomi-

nal, transrectal, and transgluteal) of pelvic abscess

drainage, ranging from 94% to 100% [83,91,94,96].

Complications from transvaginal drainage are infre-

quent and include bleeding, infection, underlying

organ damage, and vaginal fistula formation. Catheter

dislodgement may occur following any drainage pro-

cedure; however, this did not adversely affect patient

outcome in three of four patients in the study of Ryan

et al [94].

Summary

The interventionist can perform many emergent

procedures with ultrasound guidance, because of its

real-time, multiplanar imaging capability and porta-

bility. With the use of color Doppler, additional im-

portant information, such as aberrant vessels, can be

ascertained to help plan needle trajectory. Ultrasound

is also useful for nonemergent procedures, such as

biopsies. All interventionists are encouraged to be

facile with the use of ultrasound.

Acknowledgment

The authors thank Elena DuPont of the radiology

department at University Hospitals of Cleveland for

the line drawings and Joe Molter for assisting in the

preparation of images.

References

[1] Dodd III GD, Esola CC, Memel DS, et al. Sonogra-

phy: the undiscovered jewel of interventional radiol-

ogy. Radiographics 1996;16:1271–81.

[2] Sheafor DH, Paulson EK, Simmons CM, et al. Ab-

dominal percutaneous interventional procedures: com-

parison of CT and US guidance. Radiology 1998;

207:705–10.

[3] Lichentstein D, Hulot JS, Rabiller A, Tostivint I. Fea-

sibility and safety of ultrasound-aided thoracentesis in

mechanically ventilated patients. Intensive Care Med

1999;25:955–8.

[4] Jones PW, Moyers JP, Rogers J, Rodriquez R, et al.

Ultrasound-guided thoracentesis: is it a safer method?

Chest 2003;123:418–23.

[5] Raptopoulos V, Davis L, Lee G, Umali C, et al. Fac-

tors affecting the development of pneumothorax as-


sociated with thoracentesis. AJR Am J Roentgenol

1991;156:917–20.

[6] Alemen C, Alegre J, Armadans L, Andreu J, Falco V,

et al. The value of chest roentgenography in the diag-

nosis of pneumothorax after thoracentesis. Am J Med

1999;107:340–3.

[7] Boland GW, Lee MJ, Silverman S, Mueller PR. Inter-

ventional radiology of the pleural space. Clin Radiol

1995;50:205–14.

[8] Peterson W, Zimmerman R. Limited utility of

chest radiograph after thoracentesis. Chest 2000;4:

1038–42.

[9] Doyle JJ, Hnatiuk O, Torrington K, Slade A, Howard

R. Necessity of routine test roentgenography after

photosynthesis. Ann Intern Med 1996;124:816–20.

[10] Capizzi SA, Prakash U. Chest roentgenography after

outpatient thoracentesis. Mayo Clin Proc 1998;73:

948–50.

[11] Gervais DA, Petersein A, Lee M, Hahn P, et al. US-

guided thoracentesis: requirement for postprocedure

chest radiography in patients with receive mechani-

cal ventilation versus patients who breathe spontane-

ously. Radiology 1997;204:503–6.

[12] Mahfood S, Hix W, Aaron B, Blaes P, et al. Re-

expansion pulmonary edema. Ann Thorac Surg 1988;

45:340–5.

[13] Gascoigne A, Appleton A, Taylor R, Batchelor A,

Cook S. Catastrophic circulatory collapse following

re-expansion pulmonary oedema. Resuscitation 1996;

31:265–9.

[14] Carney M, Ravin CE. Intercostal artery laceration

during thoracentesis: increased risk in elderly pa-

tients. Chest 1979;75(4):520–2.

[15] Sahn SA. Management of complicated parapneu-

monic effusions. Am Rev Respir Dis 1993;148:

813–7.

[16] Light RW. Parapneumonic effusions and empyema.

Clin Chest Med 1985;6:55–62.

[17] Neff CC, vanSonnenberg E, Lawson D, Patton A. CT

follow-up of empyemas: pleural peels resolve after

percutaneous catheter drainage. Radiology 1990;176:

195–7.

[18] Haaga JR. Image-guided micro procedures. In: Haaga

JR, Lanzieri CF, Gilkeson RC, editors. CT and MR

imaging of the whole body. 4th edition. St. Louis:

Mosby; 2003. p. 2123–257.

[19] Moulton JS, Moore PT, Mencini RA. Treatment of

loculated pleural effusions with transcatheter intra-

cavitary urokinase. AJR Am J Roentgenol 1989;153:

941–5.

[20] Lee KS, Im J, Kim YH, Hwang SH, Bae WK, Lee

BH. Treatment of thoracic multiloculated empyemas

with intracavitary urokinase: a prospective study. Ra-

diology 1991;179:771–5.

[21] Silverman SG, Mueller PR, Saini S, Hahn PF,

Simeone JF, et al. Thoracic empyema: management

with image-guided catheter drainage. Radiology

1988;169:5–9.

[22] Hunnan GR, Flower CD. Radiologically-guided per-

cutaneous catheter drainage of empyemas. Clin Radiol

1988;39:121–6.

[23] Merriam MA, Cronan JJ, Dorfman GS, Lambiase

RE, Haas RA. Radiographically guided percutaneous

catheter drainage of pleural fluid collections. AJR

Am J Roentgenol 1988;151:1113–6.

[24] Westcott JL. Percutaneous catheter drainage of pleural

effusion and empyema. AJR Am J Roentgenol 1985;

144:1189–93.

[25] vanSonneberg E, Mueller PR, Ferrucci Jr JT. Percuta-

neous drainage of 250 abdominal abscesses and fluid

collections. Pt I. Results, failures, and complications.

Radiology 1984;151:337–41.

[26] Lee MJ, Saini S, Brink J, Hahn P, et al. Treatment of

critically ill patients with sepsis of unknown cause:

value of percutaneous cholecystostomy. AJR Am J

Roentgenol 1991;156:1163–6.

[27] Moulton JS, Benkert RE, Weisiger KH, Chambers

JA. Treatment of complicated pleural fluid collec-

tions with image-guided drainage and intracavitary

urokinase. Chest 1995;108:1252–9.

[28] Moore AV, Zuger JH, Kelley MJ. Lung abscess: an

interventional radiology perspective. Semin Interv

Radiol 1991;1:36–43.

[29] Bartlett JG. Anaerobic bacterial infections of the lung.

Chest 1987;91:901–9.

[30] Weissberg D. Percutaneous drainage of lung abscess.

J Thorac Cardiovasc Surg 1984;87:308–12.

[31] Stark DD, Federle MP, Goodman PC, Polrasky AE,

Webb WR. Differentiating lung abscess and empy-

ema: radiography and computed tomography. AJR


[32] Rice TW, Ginsberg RJ, Todd TR. Tube drainage of

lung abscesses. Ann Thorac Surg 1987;44:356–9.

[33] Guarner C, Runyon BA. Spontaneous bacterial peri-

tonitis: pathogenesis, diagnosis, and management.

Gastroenterologist 1995;3(4):311–28.

[34] Goletti O, Ghiselli G, Lippolis PV, Chiarugi M, Brac-

cini G, Macaluso C, et al. The role of ultrasonography

in blunt abdominal trauma: results in 250 consecutive

cases. J Trauma 1994;36:178–81.

[35] Lam EY, McLafferty RB, Taylor Jr LM, Moneta

GL, et al. Inferior epigastric artery pseudoaneurysm:

a complication of paracentesis. J Vasc Surg 1998;28:

566–9.

[36] Webster ST, Brown KL, Lucey MR, Nostrant TT.

Hemorrhagic complications of large volume ab-

dominal paracentesis. Am J Gastroenterol 1996;91:

366–8.

[37] Arnold C, Haag K, Blum HE, et al. Acute hemo-

peritoneum after large-volume paracentesis. Gastro-

enterology 1997;113:978–82.

[38] Mallory A, Schaefer JW. Complications of diagnostic

paracentesis in patients with liver disease. JAMA

1978;239:628–30.

[39] Ross GJ, Kessler HB, Clair MR, Gatenby RA, et al.

Sonographically guided paracentesis for palliation of

symptomatic malignant ascites. AJR Am J Roent-

genol 1989;153:1309–11.


[40] Boland G, Slater G, Lu D, Eisenberg P, et al. Preva-

lence and significance of gallbladder abnormalities

seen on sonography in intensive care unit patients.

AJR Am J Roentgenol 2000;174:973–7.

[41] Boland GW, Lee MJ, Leung J, et al. Percutaneous

cholecystostomy in critically ill patients: early re-

sponse and final outcome in 82 patients. AJR Am J

Roentgenol 1994;163:339–42.

[42] vanSonnenberg E, D’Agostino H, Sanchez R, Casola

G. Percutaneous abscess drainage. Radiology 1992;

184:27–9.

[43] vanOverhagen H, Meyers H, Tilanus HW, Jeekel J,

Lemeris JS. Percutaneous cholecystectomy for pa-

tients with acute cholecystitis and an increased surgi-

cal risk. Cardiovasc Intervent Radiol 1996;19:72–6.

[44] Chopra S, Dodd G, Mumbower A, Chintapalli K, et al.

Treatment of acute cholecystitis in non-critically ill

patients at high surgical risk: comparison of clinical

outcomes after gallbladder aspiration and after per-

cutaneous cholecystostomy. AJR Am J Roentgenol

2001;176:1025–31.

[45] England RE, McDermott VG, Smith TP, Suhocki PV,

Payne CS, Newman GE. Percutaneous cholecys-

tostomy: who responds? AJR Am J Roentgenol 1997;

168:1247–51.

[46] Browning PD, McGahan JP, Gersovich EO. Percuta-

neous cholecystostomy for suspected acute cholecys-

titis in the hospitalized patient. J Vasc Interv Radiol

1993;4:531–8.

[47] Boggi U, Di Candio G, Campetelli A, et al. Percu-

taneous cholecystostomy for acute cholecystitis in criti-

cally ill patients. Hepatogastroenterology 1999;46:

121–5.

[48] Garber SJ, Mathleson J, Cooperberg P, MacFarlane

J. Percutaneous cholecystostomy: safety of the trans-

peritoneal route. J Vasc Interv Radiol 1994;5:295–8.

[49] Hatzidakis AA, Prassopoulos P, Petinarakis I, et al.

Acute cholecystitis in high-risk patients: percuta-

neous cholecystostomy vs conservative treatment.

Eur Radiol 2002;12:1778–84.

[50] Teplick SK, Brandon JC, Wolferth CC, Amron G,

Gambescia R, Zitomer N. Percutaneous interventional

gallbladder procedures: personal experience and liter-

ature review. Gastrointest Radiol 1990;15:133–6.

[51] Nemcek Jr AA, Bernstein JE, Vogelzang RL. Percu-

taneous cholecystostomy: does transhepatic puncture

preclude a transperitoneal catheter route? J Vasc

Interv Radiol 1991;2:543–7.

[52] Verbanck JJ, Demol JW, Ghillebert GL, Rutgeerts

LJ, Surmont IP. Ultrasound-guided puncture of the

gallbladder for acute cholecystitis. Lancet 1993;341:

1132–3.

[53] D’Agostino H, vanSonnenberg E, Sanchez R, Gooda-

cre B, Casola G. Imaging of the percutaneous chole-

cystostomy tract: observations and utility. Radiology

1991;181:675–8.

[54] Teplick SK. Diagnostic and therapeutic interventional

gallbladder procedures. AJR Am J Roentgenol 1989;

152:913–6.

[55] Patel M, Miedema BW, James MA, Marshall JB.

Percutaneous cholecystostomy is an effective treat-

ment for high-risk patient: with acute cholecystitis.

Am Surg 2000;66:33–7.

[56] vanSonnenberg E, Wittich GR, Goodacre BW, Casola

G. Percutaneous abscess drainage: update. World J

Surg 2001;25:362–9.

[57] Nakamoto DA, Haaga JR. Percutaneous drainage of

postoperative intra-abdominal abscesses and collec-

tions. In: Cope C, editor. Current techniques in in-

terventional radiology. 2nd edition. Philadelphia:

Current Medicine; 1995. p. 111–23.

[58] Lambiase RE, Deyoe L, Cronan JJ, et al. Percuta-

neous drainage of 335 consecutive abscesses: results

of primary drainage with 1-year follow-up. Radiology

1992;184:167–79.

[59] VanSonnenberg E, D’Agostino HB, Casola G,

Goodacre BW, et al. US-guided transvaginal drain-

age of pelvic abscesses and fluid collections. Radiol-

ogy 1991;181:53–6.

[60] McNicholas MM, Mueller PR, Lee MJ, Echeverri J,

et al. Percutaneous drainage of subphrenic fluid col-

lections that occur after splenectomy: efficacy and

safety of transpleural versus extrapleural approach.

AJR Am J Roentgenol 1995;165:355–9.

[61] Shankar S, van Sonneberg E, Silverman SG, Tuncali

K. Interventional radiology procedures in the liver:

biopsy, drainage, and ablation. Clin Liver Dis 2002;

6:91–118.

[62] Brandt KR, Charboneau JW, Stephens DH, et al. CT-

and US-guided biopsy of the pancreas. Radiology

1993;187:99–104.

[63] Boland GW, Lee MJ, Mueller PR, Dawson SL, et al.

Gallstones in critically ill patients with acute calculus

cholecystitis treated by percutaneous cholecystos-

tomy: nonsurgical therapeutic options. AJR Am J

Roentgenol 1994;162:1101–3.

[64] Mueller PR, Ferrucci Jr JT, Butch RJ, Simeone JR,

et al. Inadvertent percutaneous catheter gastroenteros-

tomy during abscess drainage: significance and man-

agement. AJR Am J Roentgenol 1985;145:387–91.

[65] Papanicolaou N, Pfister RC. Acute renal infections.

Radiol Clin North Am 1996;34:965–95.

[66] Farrell TA, Hicks ME. A review of radiologically

guided percutaneous nephrostomies in 303 patients.

J Vasc Interv Radiol 1997;8:769–74.

[67] Lucey BC, Boland GW, Maher MM, Hahn PF,

et al. Percutaneous nonvascular splenic intervention:

a 10-year review. AJR Am J Roentgenol 2002;179:

1591–6.

[68] Green BT. Splenic abscess: report of six cases and

review of the literature. Am Surg 2001;67:80–5.

[69] Thanos L, Dailiana T, Papaioannou G, et al. Percuta-

neous CT-guided drainage of splenic abscess. AJR


[70] Schuster MR, Crummy AB, Wojtowycz MM, et al.

Abdominal abscesses associated with enteric fistulas:

percutaneous management. J Vasc Interv Radiol 1992;

3:359–63.


[71] Gazelle GS, Mueller PR. Abdominal abscess: imag-

ing and intervention. Radiol Clin North Am 1994;32:

913–32.

[72] Casola G, vanSonneberg E, Neff CC, et al. Abscesses

in Crohn’s disease: percutaneous drainage. Radiology

1987;163:19–22.

[73] Khuroo MS, Zargar SA, Mahajan R. Echinococcus

granulosus cysts in the liver: management with per-

cutaneous drainage. Radiology 1991;180:141–5.

[74] Bret PM, Fond A, Bretagnolle M, Valette PJ, et al.

Percutaneous aspiration and drainage of hydatid cysts

in the liver. Radiology 1988;168:617–20.

[75] Sayek I, Onat D. Diagnosis and treatment of uncom-

plicated hydatid cyst of the liver. World J Surg 2001;

25:21–7.

[76] Filice C, Pirola F, Brunetti E, et al. A new therapeutic

approach for hydatid liver cysts: aspiration and alco-

hol injection under sonographic guidance. Gastroen-

terology 1990;98:1366–8.

[77] Men S, Hekimoglu B. Percutaneous treatment of he-

patic hydatid cysts: an alternative to surgery. AJR Am

J Roentgenol 1999;172:83–9.

[78] Ustunsoz B, Akhan O, Kamiloglu MA, Somuncu I,

Ugurel MS, Cetiner S. Percutaneous treatment of hy-

datid cysts of the liver: long-term results. AJR Am J

Roentgenol 1999;172:91–6.

[79] O’Neill MJ, Rafferty EA, Lee SI, et al. Transvaginal

interventional procedures: aspiration, biopsy, and

catheter drainage. Radiographics 2001;21:657–72.

[80] Nelson AL, Sinow RM, Renslo R, et al. Endovaginal

ultrasonographically guided transvaginal drainage for

treatment of pelvic abscesses. Am J Obstet Gynecol

1995;172:1926–32.

[81] Perez-Medina T, Huertas MA, Bajo JM. Early ultra-

sound-guided transvaginal drainage of tubo-ovarian

abscesses: a randomized study. Ultrasound Obstet

Gynecol 1996;7:435–8.

[82] Casola G, vanSonnenberg E, D’Agostino HB, Harker

CP. Percutaneous drainage of tubo-ovarian abscesses.

Radiology 1992;182:399–402.

[83] Feld R, Eschelman DJ, Sagerman JE, et al. Treatment

of pelvic abscesses and other fluid collections: effi-

cacy of transvaginal sonographically guided aspira-

tion and drainage. AJR Am J Roentgenol 1994;163:

1141–5.

[84] Kuligowska E, Keller E, Ferrucci JT. Treatment of

pelvic abscesses: value of one-step sonographically

guided transrectal needle aspiration and lavage. AJR


[85] Nosher JL, Winchman HK, Needell GS. Transvaginal

pelvic abscess drainage with US guidance. Radiology

1987;165:872–3.

[86] Parsons AK. Regarding the best approach to the

pyosalpinx. Ultrasound Obstet Gynecol 1996;7:

398–400.

[87] Varghese JC, O’Neill MJ, Gervais DA, et al. Trans-

vaginal catheter drainage of tubo-ovarian abscess

using the trocar method: technique and literature re-

view. AJR Am J Roentgenol 2001;177:139–44.

[88] Sperling DC, Needleman L, Eschelman DJ, Hovse-

pian DM, et al. Deep pelvic abscesses: transperineal

US-guided drainage. Radiology 1998;208:111–5.

[89] Harisinghani MG, Dervais DA, Hahn PF, et al. CT-

guided transgluteal drainage of deep pelvic abscesses:

indications, technique, procedure-related complica-

tions, and clinical outcome. Radiographics 2002;22:

1353–67.

[90] Gervais DA, Hahn PF, O’Neill MJ, Mueller PR. CT-

guided transgluteal drainage of deep pelvic abscesses

in children: selective use as an alternative to trans-

rectal drainage. AJR Am J Roentgenol 2000;175:

1393–6.

[91] Harisinghani MG, Gervais DA, Hahn PF, et al. Trans-

gluteal approach for percutaneous drainage of deep

pelvic abscesses: 154 cases. Radiology 2003;228:

701–5.

[92] Butch RJ, Mueller PR, Ferrucci Jr JT, et al. Drainage

of pelvic abscesses through the greater sciatic fora-

men. Radiology 1986;158:487–91.

[93] Gazelle GS, Haaga JR, Stellato TA, et al. Pelvic ab-

scesses: CT-guided transrectal drainage. Radiology

1991;181:49–51.

[94] Ryan RS, McGrath PR, Haslam PJ, Varghese JC, Lee

MJ. Ultrasound-guided endocavitary drainage of pel-

vic abscesses: technique, results and complications.

Clin Radiol 2003;58:75–9.

[95] Alexander AA, Eschelman DJ, Nazarian LN, et al.

Transrectal sonographically guided drainage of deep

pelvic abscesses. AJR Am J Roentgenol 1994;162:

1227–30.

[96] Nosher JL, Needell GS, Amorosa JK, Krasna IH.

Transrectal pelvic abscess drainage with sono-

graphic guidance. AJR Am J Roentgenol 1986;146:

1047–8.

[97] McGahan JP, Brown B, Jones CD, Stein M. Pelvic

abscesses: transvaginal US-guided drainage with the

trocar method. Radiology 1996;200(2):579–81.

[98] Hovsepian DM. Transrectal and transvaginal abscess

drainage. J Vasc Interv Radiol 1997;8:501–15.

[99] Kastan DJ, Nelsen KM, Shetty PC, Burke MW, et al.

Combined transrectal sonographic and fluoroscopic

guidance for deep pelvic abscess drainage. J Ultra-

sound Med 1996;15:235–9.

[100] Abbitt PL, Goldwag S, Urbanski S. Endovaginal so-

nography for guidance in draining pelvic fluid collec-

tions. AJR Am J Roentgenol 1990;154:849–50.

[101] VanDerKolk HL. Small, deep pelvic abscesses: defi-

nition and drainage guided with an endovaginal probe.

Radiology 1991;181:283–4.

[102] Kuligowska E, Keller E, Ferrucci JT. Treatment of

pelvic abscesses: value of one-step sonographically

guided transrectal needle aspiration and lavage. AJR


[103] Aboulghar MA, Mansour RT, Serour GI. Ultra-

sonographically guided transvaginal aspiration of

tubo-ovarian abscesses and pyosalpinges: an optional

treatment for acute pelvic inflammatory disease. Am

J Obstet Gynecol 1995;172:1501–3.


[104] Caspi B, Zalel Y, Or Y, Bar Dayan Y, et al. Sono-

graphically guided aspiration: an alternative therapy

for tubo-ovarian abscess. Ultrasound Obstet Gynecol

1996;7:439–42.

[105] Corsi PJ, Johnson SC, Gonik B, Hendrick SL, et al.

Transvaginal ultrasound-guided aspiration of pel-

vic abscesses. Infect Dis Obstet Gynecol 1999;7:

216–21.

[106] Wroblicka JT, Kuligowska E. One-step needle as-

piration and lavage for the treatment of abdominal

and pelvic abscesses. AJR Am J Roentgenol 1998;

170:1197–203.

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