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TPS 23 x 31 - 2 | 15.09.14 - 12:42 TPS 23 x 31 - 2 | 15.09.14 - 12:42 TPS 23 x 31 - 2 | 15.09.14 - 12:42 Interventional Ultrasound A Practical Guide and Atlas Christoph F. Dietrich, MD Professor and Head Physician Medical Clinic 2 Caritas Hospital Bad Mergentheim gGmbH Bad Mergentheim, Germany Dieter Nuernberg, MD Professor and Head Physician Medical Clinic B Ruppiner Hospitals GmbH Neuruppin, Germany 380 illustrations Thieme Stuttgart • New York • Delhi • Rio TPS 23 x 31 - 2 | 15.09.14 - 12:42 Library of Congress Cataloging-in-Publication Data Interventioneller Ultraschall. English. Interventional ultrasound : a practical guide and atlas / [edited by] Christoph F. Dietrich, Dieter Nuernberg ; translator, Terry C. Telger ; illustrator, Helmut Holtermann. p. ; cm. Includes bibliographical references and index. ISBN 978-3-13-170821-2 – ISBN 978-3-13-170831-1 (eISBN) I. Dietrich, Christoph Frank, editor. II. Nuernberg, Dieter, editor. III. Title. [DNLM: 1. Ultrasonography, Interventional. WN 208] RC78.7.U4 616.07'543–dc23 2014028919 This book is an authorized translation of the German edition published and copyrighted 2011 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Interventionelle Ultraschall: Lehrbuch und Atlas für die Interventionelle Songraphie Translator: Terry C. Telger, Fort Worth, TX, USA Illustrator: Helmut Holtermann, Dannenberg, Germany © 2015 Georg Thieme Verlag KG Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, customerservice@thieme.de Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001, USA 1-800-782-3488, customerservice@thieme.com Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, customerservice@thieme.in Thieme Publishers Rio, Thieme Publicações Ltda. Argentina Building, 16th Floor, Ala A, 228 Praia do Botafogo Rio de Janeiro 22250-040 Brazil +55 21 3736-3631 Cover design: Thieme Publishing Group Typesetting by Thomson Digital, India Printed in Germany by Aprinta Druck, Wemding ISBN 978-3-13-170821-2 Also available as an e-book: eISBN 978-3-13-170831-1 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. 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This applies in particular to photostat reproduction, copying, mimeographing preparation of microfilms, and electronic data processing and storage. Dietrich - Interventional Ultrasound | 15.09.14 - 14:06 Contents Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii General Aspects of Interventional Ultrasound 1 Interventional Ultrasound: Introduction and Historical Background . . . . . . . . . . . . . 2 H. Lutz 1.1 The Vienna Congress . . . . . . . . . . . . . . . . . 2 1.2 The Introduction of Ultrasound into Routine Clinical Use . . . . . . . . . . . . . . . . . . 3 1.2.1 1.2.4 Risks of Interventional Ultrasound . . . . . . . 9 1.3 Later Developments: UltrasoundGuided Therapeutic Interventional Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.2.3 The Evolution of Ultrasound Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . Technical Evolution of Ultrasound-Guided Biopsies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Application . . . . . . . . . . . . . . . . . . . . 2 Interventional Materials and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.1 General Considerations on Interventional Procedures . . . . . . . . . . . . U. Gottschalk, C. F. Dietrich 13 2.1.1 2.1.2 2.1.3 Brief Historical Introduction . . . . . . . . . . . . Biopsy Principles and Techniques. . . . . . . . Needle Systems . . . . . . . . . . . . . . . . . . . . . . . 13 13 15 2.2 Therapeutic Interventions . . . . . . . . . . . . 20 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . Brief Historical Review . . . . . . . . . . . . . . . . . Patient Preparation . . . . . . . . . . . . . . . . . . . . Access Routes . . . . . . . . . . . . . . . . . . . . . . . . . Indications and Contraindications . . . . . . . 20 20 21 21 21 Complications . . . . . . . . . . . . . . . . . . . . . . . . Needle Techniques . . . . . . . . . . . . . . . . . . . . Special Needle Types. . . . . . . . . . . . . . . . . . . Trocar Technique . . . . . . . . . . . . . . . . . . . . . . Seldinger Technique . . . . . . . . . . . . . . . . . . . Peel-Away Sheath . . . . . . . . . . . . . . . . . . . . . Anchor Systems, Suture Techniques . . . . . . Guidewires . . . . . . . . . . . . . . . . . . . . . . . . . . . Dilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drainage Catheters . . . . . . . . . . . . . . . . . . . . Other Drainage Systems . . . . . . . . . . . . . . . . Accessories . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 23 23 23 24 24 25 26 27 27 29 29 31 3 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.2.2 3 1.4 4 7 2.2.6 2.2.7 2.2.8 2.2.9 2.2.10 2.2.11 2.2.12 2.2.13 2.2.14 2.2.15 2.2.16 2.2.17 D. Nuernberg, A. Jung 3.1 What Should Be Disclosed? . . . . . . . . . . . 32 3.2 Means of Disclosure . . . . . . . . . . . . . . . . . . 32 3.1.1 3.1.2 3.1.3 Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . Explaining the Procedure. . . . . . . . . . . . . . . Risks and Complications. . . . . . . . . . . . . . . . 32 32 32 3.2.1 3.2.2 3.2.3 Consent Form. . . . . . . . . . . . . . . . . . . . . . . . . Informed Consent Discussion . . . . . . . . . . . Delegating Informed Consent . . . . . . . . . . . 32 32 33 v Dietrich - Interventional Ultrasound | 15.09.14 - 14:06 Contents 3.3 Documentation . . . . . . . . . . . . . . . . . . . . . . 33 3.5.2 3.4 Timing of the Consent Process . . . . . . . . 33 3.5 Special Situations . . . . . . . . . . . . . . . . . . . . 33 3.5.3 3.5.4 3.5.5 33 Patients Lacking the Capacity to Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . Minors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Language Barriers . . . . . . . . . . . . . . . . . . . . . Waiving of Informed Consent . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 33 34 34 34 3.5.1 Implied Consent . . . . . . . . . . . . . . . . . . . . . . 4 Medications, Equipment, and Setup Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 D. Nuernberg, A. Jung 4.1 Medications . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.2.3 4.1.1 4.1.2 4.1.3 4.1.4 Premedication . . . . . . . . . . . . . . . . . . . . . . . . Analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coagulation . . . . . . . . . . . . . . . . . . . . . . . . . . Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . 35 35 36 36 4.2.4 4.2.5 4.2.6 4.2.7 4.2.8 4.2 Equipment and Setup Requirements . . 37 4.2.1 4.2.2 Biopsy Equipment . . . . . . . . . . . . . . . . . . . . . Interventional Materials. . . . . . . . . . . . . . . . 37 37 5 Pathology and Cytology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Positioning, Preprocedure Examination, and Marking. . . . . . . . . . . . . . . . . . . . . . . . . . Monitoring During the Procedure. . . . . . . . Postprocedure Monitoring. . . . . . . . . . . . . . Facilities (Procedure Room) . . . . . . . . . . . . . Functional and Design Requirements. . . . . Operational and Organizational Requirements. . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 37 37 37 38 38 38 40 A. Tannapfel, C. F. Dietrich 5.1 Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 5.4.2 Grading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5.2 Biopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 5.5 Specific Analysis . . . . . . . . . . . . . . . . . . . . . 43 5.2.1 Types of Biopsy Procedure . . . . . . . . . . . . . . 40 5.5.1 5.5.2 Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . Lymphomas . . . . . . . . . . . . . . . . . . . . . . . . . . 43 45 5.3 Histology or Cytology? . . . . . . . . . . . . . . . 40 5.6 5.3.1 Sources of Error . . . . . . . . . . . . . . . . . . . . . . . 41 Hormone Growth Factor Receptor Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 5.4 Typing, Grading, and Staging . . . . . . . . . 41 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 5.4.1 Classification (Typing). . . . . . . . . . . . . . . . . . 41 6 Fine Needle Aspiration Cytology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 C. Jenssen, T. Beyer vi 6.1 Specimen Collection . . . . . . . . . . . . . . . . . 49 6.1.1 6.1.2 Ultrasound-Guided Biopsy . . . . . . . . . . . . . Needle Movement and Aspiration . . . . . . . 6.2 49 49 6.3.1 6.3.2 6.3.3 6.3.4 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . Air Drying and Romanowsky Stains . . . . . . Wet Fixation and Papanicolaou Staining . . Ancillary Tests . . . . . . . . . . . . . . . . . . . . . . . . 55 55 55 56 Specimen Preparation . . . . . . . . . . . . . . . . 49 6.4 Cytomorphologic Evaluation . . . . . . . . . . 58 6.2.1 6.2.2 6.2.3 Fluid Aspirates . . . . . . . . . . . . . . . . . . . . . . . . Centrifuging Effusions . . . . . . . . . . . . . . . . . Aspirates from Solid Lesions . . . . . . . . . . . . 49 49 50 6.4.1 6.4.2 Rapid On-Site Evaluation . . . . . . . . . . . . . . . Final Cytologic Diagnosis . . . . . . . . . . . . . . . 58 63 6.3 Fixation and Staining . . . . . . . . . . . . . . . . . 55 6.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 64 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Dietrich - Interventional Ultrasound | 15.09.14 - 14:06 Contents 7 Infections and Diagnostic Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 T. Glueck, H. J. Linde, C. F. Dietrich 7.1 General Principles of Microbiological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 7.1.1 7.1.2 Microbiological Specimens . . . . . . . . . . . . . Prerequisites for Microbiological Testing. . 68 68 7.2 Microbiological Techniques . . . . . . . . . . . 69 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 Stains. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture Techniques . . . . . . . . . . . . . . . . . . . . Nucleic Acid Amplification Techniques . . . Serology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . When Are Microbiological Test Results Available? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 71 71 71 8 7.2.6 7.2.7 7.3 7.3.1 7.3.2 Limitations of Microbiological Methods . . Specimen Receipt during Off-hours (Nights, Weekends, Holidays) . . . . . . . . . . . 72 72 Specific Guidelines for Microbiological Testing and Differential Diagnosis by Organ Systems and Syndromes . . . . . . . 73 Investigation of Enlarged Lymph Nodes. . . Microbiological Testing and Antimicrobial Therapy for Suspected Tuberculosis . . . . . . Liver Mass Suspicious for an Abscess (Including Amebic Abscess) . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 81 Hygiene Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 7.3.3 72 73 76 H. Martiny, D. Nuernberg 8.1 General Hygienic Requirements . . . . . . . 82 8.1.1 Personal Protective Equipment and Coverings . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disposable Probe Covers . . . . . . . . . . . . . . . Ultrasound Gel. . . . . . . . . . . . . . . . . . . . . . . . 82 83 83 Hand Antisepsis and Skin Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . 83 8.1.2 8.1.3 8.2 9 8.3 Ultrasound Probe and Accessories. . . . . 8.3.1 Decontamination of the Ultrasound Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Decontamination of Ultrasound Accessories . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.2 Contraindications, Complications, and Complication Management . . . . . . . . . . . . . . 84 84 85 85 86 C. Jenssen, C. F. Dietrich 9.1 Interventional Risk . . . . . . . . . . . . . . . . . . . 86 9.1.1 9.1.2 Complication Rates and Mortality . . . . . . . Factors that Influence Interventional Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 9.2 Frequent Complications and Their Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.5 9.3.6 Prevention of Infection . . . . . . . . . . . . . . . . . Optimal Approach and Alternatives . . . . . . 93 93 9.4 Contraindications . . . . . . . . . . . . . . . . . . . . 93 9.4.1 9.4.2 93 9.4.3 Coagulopathies . . . . . . . . . . . . . . . . . . . . . . . Procoagulant Therapy and Antiplatelet Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Risky” Lesions and Access Routes . . . . . . . 86 86 94 94 9.2.1 9.2.2 9.2.3 9.2.4 Pain and Vasovagal Reactions . . . . . . . . . . . Bleeding Complications . . . . . . . . . . . . . . . . Needle Tract Seeding . . . . . . . . . . . . . . . . . . Specific Complications . . . . . . . . . . . . . . . . . 86 87 88 89 9.5 Management of Complications . . . . . . . 95 9.5.1 9.3 Prevention of Complications . . . . . . . . . . 89 9.5.2 Postinterventional Care and Detection of Complications . . . . . . . . . . . . . . . . . . . . . . . . Treatment of Complications. . . . . . . . . . . . . 95 95 9.3.1 Risk Assessment and Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modification of Risk Factors. . . . . . . . . . . . . Risk Reduction Techniques . . . . . . . . . . . . . Local Anesthesia and Intravenous Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6 Specific Biopsy Sites. . . . . . . . . . . . . . . . . . 95 9.6.1 9.6.2 9.6.3 9.6.4 Liver Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . Renal Biopsy. . . . . . . . . . . . . . . . . . . . . . . . . . Pancreatic Biopsy . . . . . . . . . . . . . . . . . . . . . Splenic Biopsy . . . . . . . . . . . . . . . . . . . . . . . . 95 99 99 100 9.3.2 9.3.3 9.3.4 89 90 92 92 vii Dietrich - Interventional Ultrasound | 15.09.14 - 14:06 Contents 9.6.5 9.7.3 9.7.4 Transrectal Prostatic Biopsy. . . . . . . . . . . . . Ultrasound-Guided Drainage (of Cysts, Pseudocysts, Abscesses, Cholecystitis) . . . . Ultrasound-Guided PTCD and Cholecystotomy . . . . . . . . . . . . . . . . . . . . . . . Ultrasound-guided Tumor Ablation Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6.6 9.6.7 Biopsy of Gastrointestinal Hollow Organs and Mesenteric Masses. . . . . . . . . . . . . . . . . Adrenal Biopsy. . . . . . . . . . . . . . . . . . . . . . . . Lungs, Pleura, and Mediastinum . . . . . . . . . 100 100 101 9.7.5 9.7 Specific Interventions . . . . . . . . . . . . . . . . 101 9.7.6 9.7.1 9.7.2 EUS-FNA, EUS-TCB, EBUS-TBNA . . . . . . . . . EUS-Guided Therapeutic Interventions . . . 101 101 10 Assistance in Ultrasound Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 102 103 103 104 109 U. Gottschalk, C. F. Dietrich 10.1 Basic Principles . . . . . . . . . . . . . . . . . . . . . . 109 10.6 Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 10.2 Duties of Assisting Personnel . . . . . . . . . 109 10.7 Drain Placement . . . . . . . . . . . . . . . . . . . . . 111 10.3 Diagnostic Ultrasound. . . . . . . . . . . . . . . . 110 10.8 Endosonography . . . . . . . . . . . . . . . . . . . . . 113 10.4 Diagnostic Interventions . . . . . . . . . . . . . 110 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 10.5 Therapeutic Interventions . . . . . . . . . . . . 111 11 Sedation in Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 U. Gottschalk, C. F. Dietrich 11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 114 11.6 Complications . . . . . . . . . . . . . . . . . . . . . . . 115 11.2 Medications . . . . . . . . . . . . . . . . . . . . . . . . . 114 11.7 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 11.3 Personnel Requirements. . . . . . . . . . . . . . 114 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 11.4 Monitoring Requirements . . . . . . . . . . . . 115 11.5 Postprocedure Care . . . . . . . . . . . . . . . . . . 115 Indications for Diagnostic Interventions in the Abdomen and Thorax (Liver, Pancreas, Spleen, Kidneys, Lung, Other Sites). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Specific Ultrasound-Guided Procedures: Abdomen 12 H. Kinkel, D. Nuernberg viii 12.1 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 12.5 Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 12.1.1 12.1.2 Diffuse Liver Diseases . . . . . . . . . . . . . . . . . . Focal Liver Lesions. . . . . . . . . . . . . . . . . . . . . 120 121 12.6 Adrenal Gland . . . . . . . . . . . . . . . . . . . . . . . 125 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.7 123 Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . 125 12.2 12.3 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.8 Other Lesions . . . . . . . . . . . . . . . . . . . . . . . . 126 123 12.4 Kidneys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 124