DOI 10.1378/chest.102.2.608 1992;102;608-612Chest

 E van Sonnenberg, G Casola, H B D'Agostino, B Goodacre and R Sanchez Interventional radiology in the chest.

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medicalimagingInterventionalRadiologyin the Chest*Eric vanSonnenberg, M. D.; Giovanna Casola, M.D.;

Horacio B. D'Agostino, M.D.; Brian Goodacre, M.D.; andRobert Sanchez, M.D.

(Chest 1992; 102:608-12)D ue to both the precision of imaging and the

technical developments in needle placement andcatheterization, interventional radiology has assumedan important role in the diagnosis and treatment ofthoracic disorders. These radiologic techniques provide many benefits: they aid the pulmonologist andthoracic surgeon diagnostically, they may benefit thethoracic surgeon as a temporizing manuever, or theymay obviate surgery in selected cases. A host of

procedures is available to diagnose and treat thoracicdisorders: guided diagnostic and therapeutic thoracen

tesis; drainage of empyemas or noninfected pleuralcollections; drainage of empyemas or noninfectedpleural collections; drainage of lung and mediastinalabscesses; transthoracic biopsy of pulmonary, mediastinal, pleural, and hilar lesions; pleural sclerosis;treatment of pneumothoraces; removal of pleural foreign bodies; and brachytherapy. This chapter willhighlight the indications, techniques, and results ofinterventional radiologic procedures for various thoracic disorders.

DIAGNosIs AND TREATMENT OF Tuoi@CIC

FLUID COLLECTIONS

Diagnostic Thoracentesis

Most diagnostic thoracenteses are performed onthe ward and do not require radiologic guidance. Thevalue ofradiologic guidance for aspiration is to increasethe likelihood ofobtaining pleural fluid and to decreasethe risk ofpneumothorax. Radiologic guidance is mostuseful and appropriate when there is a small amountof fluid. The capability to guide and follow the needle

with ultrasound or computed tomography (CT) enhances the diagnostic yield. Similarly, since a blindneedle stick is avoided, pneumothorax is less likely todevelop.

Aspirated material is sent for diagnosis to thelaboratory for Gram stain and culture. Cytology pH FL(;URE1. Ultrasound-guideddrainageof loculated thoracicempy1 1 1 1 . 1 . 1 . 1 . 1 ema. Top: Ultrasonogram depicts large, hypoechoic fluid collection

ieveis, ana cnemlstry evaiuation are oDtalnea routinety. @ithirregularmarginsinapatientwithaparapneumonicempyema.Bottom: After ultrasound-guided insertion of a 12F catheter andevacuation @fpisnslent material, the collection markedly diminishedin size. The fever al)ated, and the patient recovered in five days.

*From the Departments of Radiology and Medicine, University ofCalifornia, San Diego Medical Center, San Diego.

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For large or free-flowing empyemas, ultrasound isused as the guidance system. For loculated and lessaccessible collections, CT is the modality of choice.Radiologically guided catheters may be placed de 1201)0or after a large-bore thoracostomy tube has provedineffective. The latter occurs when these tubes migrate into the major fissure or are located remote fromthe empyema.

The technique for catheter drainage initially involves placement ofa needle for diagnostic aspiration;this needle also serves for localization. If the needleis in the correct position and defines an appropriateroute, the catheter is placed in tandem adjacent tothe needle. Seldinger or trocar technique may beused; we prefer the latter, as it is more expeditiousand may be performed in ultrasound or CT, withoutmoving the patient to fluoroscopy. With multilociilatedor multiple collections, more than one catheter isindicated. Empyema drainage is effective in 80 percent to 90 percent of cases. Drainage is ineffective ifthe abnormality is tissue, rather than fluid.

Twelve-French catheters are used routinely. Theseare single-bore systems with several large holes.Percutaneous radiologic catheters are available from5F to 30F.

Complications occur in 5 percent to 10 percent ofpatients undergoing catheter drainage of empyemas.Dislodgment of the catheter is the most frequentproblem. Bleeding is rare.

Mediastinal Abscess

Mediastinal abscessesusually occur in patients whoare extremely ill; therefore, general anesthesia andformal surgical procedures may be hazardous. Thus,radiologically guided percutaneous techniques areattractive for these patients. Computed tomography isthe guidance modality of choice. Drainage may beperformed via an anterior or posterior approach. Animportant guideline is that the pathway to the collection should proceed directly into the mediastinum orthrough the pleura without traversing normal lungwhenever possible.

Mediastinal drainage often is done for esophagealleaks, which may be spontaneous or postoperative.Frequently these leaks have to be repaired surgically.Percutaneous drainage permits the patient to becleared of infection, favoring operation in a morecontrolled clinical setting.

Lung Abscesses

Percutaneous drainage of lung abscesses may expedite treatment and be curative. Most patients withlung abscesses respond well to postural drainage,coughing, and antibiotics. Those patients who cannotcough or whose bronchi are obstructed (by tumor,lymph nodes, or mucus plugs) can benefit and be

FIGURE 2. Computed tomography-guided drainage of small locu

lated empyema. Top: Computed tomographic scan depicts a smallempyema posterior to the aorta. There was consolidation in the leftlower lobe. Bottom: With patient in the prone position, CT wasused to guide catheter insertion from a posterior approach. Purulentmaterial was removed, and the catheter was allowed to drain foreight days, at which time the patient was well and the catheter waswithdrawn.

Therapeutic Thoracentesis

Small (5F to 9F) catheters may be inserted underultrasound guidance alongside the localizing guidedneedle. These catheters permit therapeutic thoracentesis for evacuation of serous or noninfected fluid.Ultrasound is the guidance procedure of choice formost thoracenteses (Fig 1); CT is reserved for loculatedcollections (Fig 2). With noninfected collections, catheters usually remain in place for a short time; withmalignant effusions, catheters frequently are left in

place for a longer period, and scierosing agents maybe infused.

DRAINAGE OF INFECTED COLLECTIONS

Empyema

If diagnostic aspiration reveals infection by Gramstain or by culture, percutaneous drainage is indicated.

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cured by catheter drainage. The preferential accessroute is through contiguous abnormal pleura. Thisensures that normal lung will not be punctured andthat bronchopleural fistula is not likely to develop.Lung abscesses are cured percutaneously in 80 percentto 100 percent of cases.

Scierotherapy

Sclerotherapy into the pleural cavity is done forrecurrent malignant effusion. Tetracycline is used most

frequently to induce sclerosis. A typical dose for

infusion is 500 mg to 1 g, diluted in normal saline

solution. Multiple sessions often are necessary forsuccessful treatment. A 7F pigtail catheter suffices forsclerotherapy. Catheters that are placed for infusiontherapy can be removed promptly if multisessiontherapy is not chosen.

BRACHYTH ERAPY

Brachytherapy is performed for recurrent or refractory tumor that abuts, or is in, the pleural space. A

fine needle for localization is inserted into the recur

rent tumor. This is followed by placement of a large(16-gauge)needleintothelesion.Severalneedlesmayl)e necessary. Radiation pellets are loaded into thelarge needles for local therapy. Tumor shrinkage hasoccurred in some patients. Care must be taken in

placing these large needles; the potential for bleedingor pneumothorax exists and theoretically is greaterthan with fine needles.

PERCUTANEOUS THORACIC BIOPSY

Biopsy of Pulmonary and Pleural Lesions

Fluoroscopic, CT, or sonographic guidance may beIlsed for percutaneous biopsy. Fluoroscopy is chosen

whenever possible, due to its ease and relatively lowcost. Ifa lesion isvisible in two 9O@planes,fluoroscopicguidance is adequate. In general, lesions greater than

1.5 to 2 cm are amenable to fluoroscopic biopsy;lesions measuring 0.5 to 1 .5 cm are appropriate for

CT guidance. Computed tomography is particularlyadvantageous for lesions that are not seen in twoplanes on conventional radiography. Ultrasound mayl)e used for pleural lesions or large pulmonary lesionsthat abut the pleura. Sonography has the advantagethat neither the patient nor the operator is exposed toradiation. Computed tomography permits accurateand unequivocal documentation of needle position inthe lesion.

The main drawback to CT guidance is developmentof a pneumothorax; the lesion may retract from itsoriginal position, and all original localization becomesinvalid. To relocalize the lesion would be impractical,due to time considerations (and occasionally the

patient is too symptomatic). Since fluoroscopy is donein real-time, despite the presence of a pneumothorax

(as opposed to CT), the needle still may be directedinto the lesion. If a large pneumothorax developsunder CT, the pneumothorax must be evacuatedimmediately to continue the biopsy.

Diagnosis by transthoracic biopsy is achieved in 70percent to 90 percent of cases. An assortment ofbenign conditions, including histoplasmosis, coccidioidomycosis, tuberculosis, nocardiosis, aspergillosis,mucormycosis, hamartoma, and bacterial and opportunistic infections, may be diagnosed. The typicalassortment of bronchogenic, metastatic, and less common pulmonary tumors (carcinoid, lymphoma) all maybe diagnosed by percutaneous biopsy.

Pneumothorax occurs in 10 percent to 60 percent

of patients undergoing percutaneous biopsy. A chest

tube is inserted in 5 percent to 25 percent of patients.Pulmonary hemorrhage, hemothorax, and pain areless frequent complications.

PERCUTANEOUS BIOPSY OF MEDIASTINAL AND

HILAR LESIONS

When fluoroscopy was the sole guidance method,mediastinal and hilar lesions were considered hazardous for transthoracic biopsy by most authors. Presently,CT permits precise localization of major vessels,thereby allowing safe biopsy in most cases of mediastinal and hilar lesions. With current high-resolutionCT, biopsy specimens of most hilar and mediastinallesions larger than 1 cm may be obtained under CTguidance.

A frequently used system for biopsy is the coaxialtechnique, in which an outer needle slides over aninner localizing needle (Fig 3). After removal of theinner guiding needle, multiple biopsy passes areobtained coaxially through the outer cannula by 21- or

FIGuRE 3. Computed tomography-guided biopsy of perthilar malig

nant neoplasm. Use of fine-needle, coaxial CT technique allowedbetter delineation of vessels and lesion. Final diagnosis was metastatic renal cell carcinoma.

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FIGURE 4. Radiologic treatment of pneuinothorax. Left: Immediately after CT-guided biopsy of a small

nodule in the right lower lobe, the patient developed pleuritic pain and dyspnea due to tensionpneumothorax. Right: After immediate insertion of a 7F pneum@th@rax catheter, pneumothorax was

evacuated, and patient became asymptomatic.

22-gauge needles. Biopsy specimens may be obtainedfrom mediastinal lesions in the pretracheal, anteroposterior window, and subcarinal regions and frompericardial and diaphragmatic nodes. Specimens fromlesions in the anterior, middle, and posterior mediastinal regions may be obtained as well.

Major complications of these biopsies are uncommon and include bleeding, pneumothorax, pericarditis, and pericardial tamponade. Mediastinal and hilarbiopsies permit staging of pulmonary malignancy, andmay preclude unnecessary thoracotomy if a diagnosisof incurability is made on the basis of the biopsyfindings.

TREATMENT OF PNEUMOTHORAX

It is well established that pneumothoraces may be

treated with small, radiologic-type catheters (Fig 4).Treatment is done either during or after transthoracicbiopsy. In the former instance, the CT-guided biopsymay continue by reexpansion of the lung that bringsthe lesion back to the original site of localization.

By convention, catheters are inserted in the secondintercostal space in the midclavicular line. However,when a biopsy is being done with the patient in theprone position, the catheter may be inserted in theaxillary line or even somewhat posterior to obviateturning the patient (twice) and using valuable CTtime. A 7F catheter inserted by direct trocar puncturegenerally suffices to treat pneumothorax. Pneumotho

races may be evacuated by syringe, suction, pleurevac,or water seal or with a Heimlich valve.

Once the pneumothorax has been evacuated andreexpansion has been confirmed radiographically, thetube is clamped. After 4 h, a repeat chest x-ray film isobtained. Ifthe pneumothorax remains evacuated, thechest catheter may be removed. Conversely, if thepneumothorax reaccumulates, drainage should continue.

Complications are few with this technique. Patientsmay experience pain after complete evacuation of thepneumothorax; injecting a tiny bit of air (about 10 ml)to move the catheter away from the pleura slightly isenough to relieve this discomfort.

SUMMARY

Interventional radiologic techniques offer manyoptions and benefits in the care of patients withthoracic disorders. Imaging-guided catheter techniques provide heretofore unsurpassed precision andaccuracy in performance of these procedures. Improved efficacy, with reduced morbidity is the goaland usually the result for the patient.

ACKNOWLEDGMENTS: The authors would like to express theirappreciation to Mrs Peggy Chambers and to Mike Hearns, R.T.

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DOI 10.1378/chest.102.2.608 1992;102; 608-612Chest

E van Sonnenberg, G Casola, H B D'Agostino, B Goodacre and R SanchezInterventional radiology in the chest.

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