Enhancing your practice: debriefing in interventional radiology

LEARNING OBJECTIVES

Review the history of debriefing and provide an Interventional Radiologist (IR) specific framework for leading an effective debrief.

BACKGROUND

A debrief is often regarded as a meeting with persons who were involved in a stressful, traumatic and/or emotionally challenging situation to review processes, communicate concerns or gather feedback. The goals of these sessions can be for learning/quality improvement (QI) or psychological/emotional support, or a mix of both. Debriefing after tough situations has become a standard tool of many medical specialties, such as surgery, critical care and emergency medicine, with specialty specific literature available. However, there is a paucity of Interventional Radiology specific literature available for debriefing techniques.

CLINICAL FINDINGS/PROCEDURE DETAILS

We will review the history and types of debriefing and why a debrief could be considered. We will provide a framework for leading a successful debrief in Interventional Radiology.

CONCLUSION

Debriefing can be a useful tool for learning and QI as well as psychological or emotional support after a challenging or tough situation. Debriefing can address multiple variables and can stylistically be tailored to suit specific needs. IRs have an opportunity to take a leadership role in debriefing, providing comfort and quality improvement through communication and support.

Inferior vena cava filter tilting between placement and retrieval is associated with caval diameter and need for complex retrieval techniques

PURPOSE

Inferior vena cava (IVC) filter tilt may lead to apex embedment and need for advanced retrieval techniques. This study assesses factors associated with filter tilt change over time and need for complex retrieval procedures.

MATERIALS AND METHODS

252 consecutive patients underwent retrievable IVC filter placement and removal at a single academic institution over 58 months. 182 (72.2%) patients met inclusion criteria. IVC filters included 168 (92.3%) Gunther Tulip and 14 (7.7%) Option filters. The primary outcome was medial-to-lateral IVC filter tilt change between placement and retrieval. Secondary outcomes included advanced retrieval technique use and multiple retrieval attempts. Independent variables included demographics, IVC diameter, filter hook position relative to the renal veins, and dwell time. Associations were determined using student's t-tests, ANOVA, and linear and logistic regressions.

RESULTS

Mean IVC diameter at placement was 19.2 ± 3.3 mm. Mean filter tilts at placement and retrieval were 6.1 ± 4.9° and 5.2 ± 5.0°, respectively. Mean tilt change was 5.0 ± 5.0°. Larger IVC diameter was associated with greater filter tilt change (p = 0.0004). While IVC diameter did not independently predict retrieval difficulty, greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use (p = 0.01 and 0.002, respectively). Results were unchanged in a subgroup analysis of patients treated with Gunther Tulip filters.

CONCLUSION

Larger IVC diameter predicts increased filter tilt change, which in turn is associated with challenging retrievals. Attention to IVC diameter during filter placement may anticipate tilt-related complications.

Interventional Optical Imaging Permits Instant Visualization of Pathological Zones of Ablated Tumor Periphery and Residual Tumor Detection

Optical imaging (OI) provides real-time clinical imaging capability and simultaneous molecular, morphological, and functional information of disease processes. In this study, we present a new interventional OI technique, which enables in vivo visualization of three distinct pathologic zones of ablated tumor periphery for immediate detection of residual tumors during a radiofrequency ablation (RFA) session. Rabbits with orthotopic hepatic tumors were divided into two groups (n = 8/group): incomplete RFA and complete RFA. Indocyanine green-based interventional OI was used to differentiate three pathological zones: ablated tumor, transition margin, and residual tumor or surrounding normal liver-with quantitative comparison of signal-to-background ratios among the three zones and between incompletely and completely ablated tumors. Subsequent ex vivo OI and pathologic correlation were performed to confirm the findings of interventional OI. Interventional OI could differentiate incompletely or completely ablated tumor peripheries, thus permitting identification of residual tumor. This technique may open new avenues for immediate assessment of tumor eradication during a single interventional ablation session. SIGNIFICANCE: Interventional optical imaging can instantly visualize pathologic zones of ablated tumor peripheries to detect residual tumors, which could revolutionize current image-guided interventional oncologic ablation techniques.

Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series

BACKGROUND

Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure.

CASE PRESENTATION

This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days.

CONCLUSIONS

TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

Fluoroscopically-guided interventions with radiation doses exceeding 5000 mGy reference point air kerma: a dosimetric analysis of 89,549 interventional radiology, neurointerventional radiology, vascular surgery, and neurosurgery encounters

Purpose

To quantify and categorize fluoroscopically-guided procedures with radiation doses exceeding 5000 mGy reference point air kerma (K_a,r). K_a,r > 5000 mGy has been defined as a “significant radiation dose” by the Society of Interventional Radiology. Identification and analysis of interventions with high radiation doses has the potential to reduce radiation-induced injuries.

Materials and methods

Radiation dose data from a dose monitoring system for 19 interventional suites and 89,549 consecutive patient encounters from January 1, 2013 to August 1, 2019 at a single academic institution were reviewed. All patient encounters with K_a,r > 5000 mGy were included. All other encounters were excluded (n = 89,289). Patient demographics, medical specialty, intervention type, fluoroscopy time (minutes), dose area product (mGy·cm²), and K_a,r (mGy) were evaluated.

Results

There were 260 (0.3%) fluoroscopically-guided procedures with K_a,r > 5000 mGy. Of the 260 procedures which exceeded 5000 mGy, neurosurgery performed 81 (30.5%) procedures, followed by interventional radiology (n = 75; 28.2%), neurointerventional radiology (n = 55; 20.7%), and vascular surgery (n = 49; 18.4%). The procedures associated with the highest K_a,r were venous stent reconstruction performed by interventional radiology, arteriovenous malformation embolization performed by neurointerventional radiology, spinal hardware fixation by neurosurgery, and arterial interventions performed by vascular surgery. Neurointerventional radiology had the highest mean K_a,r (7,799 mGy), followed by neurosurgery (7452 mGy), vascular surgery (6849 mGy), and interventional radiology (6109 mGy). The mean K_a,r for interventional radiology performed procedures exceeding 5000 mGy was significantly lower than that for neurointerventional radiology, neurosurgery, and vascular surgery.

Conclusions

Fluoroscopically-guided procedures with radiation dose exceeding 5000 mGy reference point air kerma are uncommon. The results of this study demonstrate that a large proportion of cases exceeding 5000 mGy were performed by non-radiologists, who likely do not receive the same training in radiation physics, radiation biology, and dose reduction techniques as radiologists.

Adrenal Vein Sampling: How I Do It

Adrenal vein sampling (AVS) is an uncommonly performed interventional procedure. However, it is essential in the management of patients with primary aldosteronism and several other rare hormonal disorders. AVS can be technically challenging, largely from difficulty with right adrenal vein catheterization. Recently described technical modifications have improved the likelihood of successful sampling in every case. This paper highlights the author's approach to patient selection and step-by-step details of his technique.

Monitoring and Follow-Up of High Radiation Dose Cases in Interventional Radiology

RATIONALE AND OBJECTIVES

To assess the implementation of radiation dose monitoring software, create a process for clinical follow-up and documentation of high-dose cases, and quantify the number of patient reported radiation-induced tissue reactions in fluoroscopically guided interventional radiology (IR) and neuro-interventional radiology (NIR) procedures.

MATERIALS AND METHODS

Web-based radiation dose monitoring software was installed at our institution and a process to flag all procedures with reference point air kerma (K_a,r) > 5000 mGy was implemented. The entrance skin dose was estimated and formal reports generated, allowing for physician-initiated clinical follow-up. To evaluate our process, we reviewed all IR and NIR procedures performed at our hospital over a 1-year period. For all procedures with K_a,r > 5000 mGy, retrospective medical chart review was performed to evaluate for patient reported tissue reactions.

RESULTS

Three thousand five hundred eighty-two procedures were performed over the 1-year period. The software successfully transferred dose data on 3363 (93.9%) procedures. One thousand three hundred ninety-three (368 IR and 1025 NIR) procedures were further analyzed after excluding 2189 IR procedures with K_a,r < 2000 mGy. Ten of 368 (2.7%) IR and 52 of 1025 (5.1%) NIR procedures exceeded estimated skin doses of 5000 mGy. All 10 IR cases were abdominal/pelvic trauma angiograms with/without embolization; there were no reported tissue reactions. Of 52 NIR cases, 49 were interventions and 3 were diagnostic angiograms. Five of 49 (10.2%) NIR patients reported skin/hair injuries, all of which were temporary.

CONCLUSION

Software monitoring and documentation of radiation dose in interventional procedures can be successfully implemented. Radiation-induced tissue reactions are relatively uncommon.

An Interventionalist's Guide to Hemoptysis in Cystic Fibrosis

Massive hemoptysis occurs in a minority of patients with cystic fibrosis, with an annual incidence of 1%. Although rare, massive hemoptysis can be a severe and potentially fatal complication of this disease. Beyond the acute life-threatening event, hemoptysis in patients with cystic fibrosis has been associated with faster decline in lung function, accelerated need for lung transplant, and increased mortality. The bronchial arteries are the culprit vessels in over 90% of cases of hemoptysis. This normally quiescent vascular system undergoes remarkable hypertrophy, collateralization, and angiogenesis before the onset of hemoptysis, introducing numerous pitfalls for the interventionalist. However, in experienced hands, bronchial artery embolization is a safe and potentially lifesaving therapy. Preprocedural noninvasive imaging, specifically computed tomographic angiography, has been repeatedly validated for helping to localize the likely site of bleeding, characterizing pertinent arterial anatomy, and promoting efficient and effective intervention; it has been recommended for all stable patients with hemoptysis. Success in the angiographic suite requires a thorough understanding of normal and variant bronchial arterial anatomy, appropriate patient selection, and a meticulous embolization technique. A meticulous approach to imaging and intervention, conscientious of both visualized and nonvisualized collateral pathways and nontarget vessels, can minimize potentially devastating complications. This review summarizes the current literature, modern procedural techniques, and emerging controversies, serving to guide an evolving approach to management of patients with cystic fibrosis and hemoptysis. ^©RSNA, 2018.

An Interventionist's Guide to Endocrine Consultations

Endocrinopathies are a heterogeneous group of disorders often resulting from pathologic sources of hormone production. When the clinical scenario, laboratory testing, and noninvasive imaging fail to aid confident identification of the source of hormone excess, endocrine venous sampling may localize obscure lesions to guide subsequent treatment. Knowledge of basic hormone signaling pathways, common pathophysiologic disruptions of these pathways, and serologic evaluation fosters informed conversations with referring physicians and effective patient selection. Success in the angiography suite requires familiarity with normal and variant anatomy of the multiple organs of the endocrine system, patient preparation, stimulation and sampling techniques, specimen handling, and results interpretation. ^©RSNA, 2017.

Yttrium-90 Radioembolization as a Salvage Treatment following Chemoembolization for Hepatocellular Carcinoma

PURPOSE

To determine safety and efficacy of yttrium-90 ((90)Y) transarterial radioembolization (TARE) in patients who have undergone chemoembolization for hepatocellular carcinoma.

MATERIALS AND METHODS

A retrospective study identified 40 patients (median age 61 y; range, 44-84 y) who underwent (90)Y mapping angiography and had undergone ≥ one prior chemoembolizations. There were 4 (10%) patients in Barcelona Clinic Liver Cancer stage A, 7 (17.5%) in stage B, and 29 (72.5%) in stage C; 28 (70%) were Child-Pugh class A and 12 (30%) were class B. Median tumor diameter was 4.2 cm (range, 1-11.6 cm). The most common indications for changing to TARE were tumor progression (35/40; 86%) and development of portal vein thrombus (15/40; 37.5%).

RESULTS

Of 40 patients, 29 (72.5%) underwent TARE; the most common reasons for not undergoing TARE were attenuated hepatic arteries (5/11), high pulmonary shunt (4/11), and poor arterial flow (2/11). Patients who underwent ≤ 4 chemoembolizations to the TARE target tended to be more likely to undergo TARE after mapping than patients who had > 4 chemoembolizations (P = .056). Most common grade ≥ 3 toxicities were fatigue (9/29; 31%) and biochemical alterations (bilirubin [3/29; 10.3%], albumin [4/29; 13.8%], aspartate aminotransferase [5/29; 17.2%]). Of 27 patients treated with TARE with follow-up, responses were 11 (41%) complete response, 5 (19%) partial response, 2 (7%) stable disease, and 9 (33%) progressive disease. Median progression-free survival and overall survival were 90 days and 257 days.

CONCLUSIONS

TARE is safe and effective salvage therapy in patients after chemoembolization. In patients who have undergone > 4 chemoembolizations to the (90)Y target, feasibility of TARE tends to be decreased.

Orthotopic Esophageal Cancers: Intraesophageal Hyperthermia-enhanced Direct Chemotherapy in Rats

Purpose To determine the feasibility of using intraesophageal radiofrequency (RF) hyperthermia to enhance local chemotherapy in a rat model with orthotopic esophageal squamous cancers. Materials and Methods The animal protocol was approved by the institutional animal care and use committee and the institutional review board. Human esophageal squamous cancer cells were transduced with luciferase lentiviral particles. Cancer cells, mice with subcutaneous cancer esophageal xenografts, and nude rats with orthotopic esophageal cancers in four study groups of six animals per group were treated with (a) combination therapy of magnetic resonance imaging heating guidewire-mediated RF hyperthermia (42°C) plus local chemotherapy (cisplatin and 5-fluorouracil), (b) chemotherapy alone, (c) RF hyperthermia alone, and (d) phosphate-buffered saline. Bioluminescent optical imaging and transcutaneous ultrasonographic imaging were used to observe bioluminescence signal and changes in tumor size among the groups over 2 weeks, which were correlated with subsequent histologic results. The nonparametric Mann-Whitney U test was used for comparisons of variables. Results Compared with chemotherapy alone, RF hyperthermia alone, and phosphate-buffered saline, combination therapy with RF hyperthermia and chemotherapy induced the lowest cell proliferation (relative absorbance of formazan: 23.4% ± 7, 44.6% ± 7.5, 95.8% ± 2, 100%, respectively; P < .0001), rendered the smallest relative tumor volume (0.65 mm³ ± 0.15, P < .0001) and relative bioluminescence optical imaging photon signal (0.57 × 10⁷ photons per second per square millimeter ± 0.15, P < .001) of mice with esophageal cancer xenografts, as well as the smallest relative tumor volume (0.68 mm³ ± 0.13, P < .05) and relative photon signal (0.56 × 10⁷ photons per second per square millimeter ± 0.11. P < .001) of rat orthotopic esophageal cancers. Conclusion Intraesophageal RF hyperthermia can enhance the effect of chemotherapy on esophageal squamous cell cancers. ^© RSNA, 2016.

Intra-Arterial Thrombolysis for Hepatic Artery Thrombosis following Liver Transplantation

PURPOSE

Hepatic artery thrombosis (HAT) is a major cause of morbidity and death following liver transplantation. The purpose of this study was to evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) in liver transplant recipients with HAT.

MATERIALS AND METHODS

Adult liver transplant recipients who underwent attempted IAT for HAT were identified. This included patients with early and late HAT (occurring less than or greater than 30 d after transplantation). Records were reviewed to determine the rates of technical success, complications, surgical revascularization, repeat liver transplantation, and ischemic cholangiopathy.

RESULTS

Twenty-six patients underwent attempted thrombolysis, 13 of whom had early HAT. IAT was successfully initiated in 23 patients (88%), with a median IAT duration of 28 hours (range, 12-90 h). Recanalization was achieved in 12 patients (46%). Major complications were observed in 11 patients (42%). The early HAT group showed a trend toward increased major bleeding compared with the late HAT group (50% vs 9%; P = .07). Among 12 patients who had technically successful thrombolysis, five (42%) required surgical revascularization or repeat transplantation within 2 months. At 6 months after thrombolysis, 45% with unsuccessful recanalization avoided surgery or development of ischemic cholangiopathy, similar to the proportion in those who had successful recanalization (42%; P = .88).

CONCLUSIONS

Posttransplantation hepatic artery thrombolysis yields suboptimal results with a high complication rate, especially in early HAT. Even with successful restoration of flow, clinical outcomes are poor. Although thrombolysis may still be considered in view of the limited treatment options for HAT, awareness of potential complications and suboptimal success rate is essential.

Frequency of external iliac artery branch injury in blunt trauma: improved detection with selective external iliac angiography

PURPOSE

To assess the utility of selective external iliac artery (EIA) angiography and the frequency of injury to branches of the EIA in cases of blunt pelvic trauma.

MATERIALS AND METHODS

A retrospective review of pelvic angiograms in 66 patients with blunt pelvic trauma was conducted over a 12-month period. Pelvic and femur fracture patterns were correlated to the presence of EIA injury. Pelvic arteriography was compared versus selective EIA angiography for the detection of arterial injury.

RESULTS

Fifty-four of 66 patients (82%) exhibited pelvic arterial injury or elicited enough suspicion for injury to warrant embolization. Internal iliac artery embolization was performed in 50 of 66 (76%). EIA branch injury was identified in 11 of 66 patients (17%), and 10 were successfully embolized. EIA branch vessel injury was identified more frequently when there was ipsilateral intertrochanteric fracture (P = .07) or ipsilateral ilium fracture (P = .07). The sensitivity of nonselective pelvic angiography in the detection of EIA branch vessel injury was 45%.

CONCLUSIONS

EIA branch injury occurs in a substantial fraction of patients with blunt pelvic trauma who undergo pelvic angiography. Selective EIA angiography should be considered in all patients undergoing pelvic angiography in this situation.

Arterial closure device to achieve hemostasis in children following percutaneous femoral arterial puncture

BACKGROUND

Percutaneous arterial closure devices have increasingly entered clinical practice to assist in achieving femoral arterial access site hemostasis. Prior studies have demonstrated the safety and efficacy of several arterial closure devices in adults.

OBJECTIVE

To evaluate the efficacy of using an arterial closure device in children.

MATERIALS AND METHODS

A retrospective review of all children (defined as younger than 18 years) undergoing device-assisted closure of their percutaneous femoral arterial access site was conducted. Patient demographics, the clinical indications for use of the arterial closure device and pre-procedural laboratory parameters were noted. The accessed common femoral artery diameter and largest procedural sheath size were recorded. The technical success rate for device deployment and rates of immediate and delayed complications including hemorrhage, access site or retroperitoneal hematoma, access site infection, arterial thromboembolism, pseudoaneurysm or arteriovenous fistulae were documented.

RESULTS

Between June 2009 and June 2011, an arterial closure device was deployed with intent to achieve hemostasis in percutaneous femoral arterial access punctures in 38 consecutive children. The mean common femoral artery diameter was 0.70 ± 0.13 cm. Device deployment was technically successful in 37/38 (97.4%) procedures. There was a single complication (2.6%), a small access site hematoma. No other immediate or delayed complications occurred.

CONCLUSION

The use of a percutaneous arterial closure device can be an efficacious method for achieving immediate femoral arterial access site hemostasis with few complications in children who have undergone percutaneous femoral arterial access procedures.

MRI-monitored intra-shunt local agent delivery of motexafin gadolinium: towards improving long-term patency of TIPS

Background

Transjugular intrahepatic portosystemic shunt (TIPS) has become an important and effective interventional procedure in treatment of the complications related to portal hypertension. Although the primary patency of TIPS has been greatly improved due to the clinical application of cover stent-grafts, the long-term patency is still suboptimal. This study was to investigate the feasibility of using magnetic resonance imaging (MRI)-monitored intra-shunt local agent delivery of motexafin gadolinium (MGd) into shunt-vein walls of TIPS. This new technique aimed to ultimately inhibit shuntstenosis of TIPS.

Methodology

Human umbilical vein smooth muscle cells (SMCs) were incubated with various concentrations of MGd, and then examed by confocal microscopy and T1-map MRI. In addition, the proliferation of MGd-treated cells was evaluated. For in vivo validation, seventeen pigs underwent TIPS. Before placement of the stent, an MGd/trypan-blue mixture was locally delivered, via a microporous balloon, into eleven shunt-hepatic vein walls under dynamic MRI monitoring, while trypan-blue only was locally delivered into six shunt-hepatic vein walls as serve as controls. T1-weighted MRI of the shunt-vein walls was achieved before- and at different time points after agent injections. Contrast-to-noise ratio (CNR) of the shunt-vein wall at each time-point was measured. Shunts were harvested for subsequent histology confirmation.

Principal Findings

In vitro studies confirmed the capability of SMCs in uptaking MGds in a concentration-dependent fashion, and demonstrated the suppression of cell proliferation by MGds as well. Dynamic MRI displayed MGd/blue penetration into the shunt-vein walls, showing significantly higher CNR of shunt-vein walls on post-delivery images than on pre-delivery images (49.5±9.4 vs 11.2±1.6, P<0.01), which was confirmed by histology.

Conclusion

Results of this study indicate that MRI-monitored intra-shunt local MGd delivery is feasible and MGd functions as a potential therapeutic agent to inhibit the proliferation of SMCs, which may open alternative avenues to improve the long-term patency of TIPS.

Which Arteries Are Expendable? The Practice and Pitfalls of Embolization throughout the Body

This article outlines general concepts of, and strategies for, therapeutic embolization throughout the body, touching on all major arterial distributions. Clinical scenarios that allow or prevent safe embolization of vessels are presented. Specific agents are recommended where appropriate, as are alternate approaches when embolization is not an option. Pre-embolization precautions and adjunctive measures are described in high-risk areas.

Ultrasound guidance for the creation of a small animal model of aortic injury

PURPOSE

To develop a small animal model of controlled aortic intimal injury with ultrasound (US) imaging guidance.

MATERIALS AND METHODS

Via carotid artery cutdown, a custom-made microcatheter/angled metal device system was advanced to damage the intima of the ascending aortas of 20 Sprague-Dawley rats and 10 JCR atherosclerotic rats. This minimally invasive endovascular procedure was monitored by a clinical US imaging system. Injured aortas were harvested for histologic confirmation via a grading system: grade I, intima injury; grade II, injury to media; and grade III, injury through the entire aortic wall. Neointimal reactions at the injury site were compared by calculating the ratio of intimal to medial thickness among different animal groups at various survival times (week 1, weeks 2-3, and weeks 4-7).

RESULTS

Clear visualization of the architecture of the heart and great vessels and the exact location of the angled metal device by US imaging ensured consistent intimal damage of the aorta. Histopathologic analysis confirmed that most of the aortic injures were classified as grade I. There was no significant difference between the two rat groups. Analysis of pathophysiologic reactions at the injury sites revealed increased thickening of neointimal hyperplasia as animal survival times extended from week 1 to weeks 4-7 after the aortic interventions.

CONCLUSIONS

This study demonstrates the feasibility of clinical US imaging to precisely guide the creation of controlled aortic intimal injury in rats, which may become a useful tool to facilitate research involving the prevention and treatment of atherosclerotic cardiovascular disease.

Endocavitary Three-dimensional Ultrasonographic Assistance for Transvaginal or Transrectal Drainage of Pelvic Fluid Collections

PURPOSE

Determine the feasibility of using three-dimensional ultrasonography (3D US) to assist in planning and performing endocavitary drainage of deep pelvic fluid collections.

MATERIALS AND METHODS

Retrospective review of images and medical records of 16 patients in whom endocavitary 3D US was used during transvaginal or transrectal drainage of 17 deep fluid collections. 3D US was assessed regarding its ability to display the relevant structures, whether new information was provided compared with pelvic computed tomography (CT) and conventional two-dimensional US (2D US) displays, and whether this information altered drainage techniques.

RESULTS

Targeted fluid collections were visualized in all patients. 3D US added information in 11 of 16 patients (69%) that, in turn, resulted in adjustment of interventional technique in eight of 16 patients (50%). Specific features of 3D US that provided new information included the simultaneous display of three orthogonal US images, display of reconstructed US image plane orientations not possible with 2D US, and the ability to interactively scroll images through complex structures to assess for communication between the loculations. An attached needle guide was used in 15 of 16 patients to improve the precision of needle placement.

CONCLUSION

Endocavitary 3D US is feasible for assistance in transvaginal and transrectal drainage procedures, usually adds new information, frequently alters interventional technique, and permits precise access needle placement.

Single-Pass Percutaneous Liver Biopsy for Diffuse Liver Disease Using an Automated Device: Experience in 154 Procedures

PURPOSE

To describe our experience with ultrasound (US)-guided percutaneous liver biopsies using the INRAD 18 G Express core needle biopsy system.

METHODS

One hundred and fifty-four consecutive percutaneous core liver biopsy procedures were performed in 153 men in a single institution over 37 months. The medical charts, pathology reports, and radiology files were retrospectively reviewed. The number of needle passes, type of guidance, change in hematocrit level, and adequacy of specimens for histologic analysis were evaluated.

RESULTS

All biopsies were performed for histologic staging of chronic liver diseases. The majority of patients had hepatitis C (134/153, 90.2%). All patients were discharged to home after 4 hr of post-procedural observation. In 145 of 154 (94%) biopsies, a single needle pass was sufficient for diagnosis. US guidance was utilized in all but one of the procedures (153/154, 99.4%). The mean hematocrit decrease was 1.2% (44.1--42.9%). Pain requiring narcotic analgesia, the most frequent complication, occurred in 28 of 154 procedures (18.2%). No major complications occurred. The specimens were diagnostic in 152 of 154 procedures (98.7%).

CONCLUSIONS

Single-pass percutaneous US-guided liver biopsy with the INRAD 18 G Express core needle biopsy system is safe and provides definitive pathologic diagnosis of chronic liver disease. It can be performed on an outpatient basis. Routine post-biopsy monitoring of hematocrit level in stable, asymptomatic patients is probably not warranted.