Performance of a New Blunt-Tip Coaxial Needle for Percutaneous Biopsy and Drainage of “Hard-To-Reach” Targets

Innovative Techniques for Image-guided Percutaneous Puncture: Navigating Complex Cases for Successful Outcomes

This article emphasizes image-guided puncture, a common technique used by interventional radiologists. It focuses on ultrasound, fluoroscopy, computed tomography, and computed tomography fluoroscopy-guided procedures. While techniques vary, successful outcomes without complications still heavily rely on operators' skill and judgment. Operators need knowledge of needle characteristics and expert needle manipulation. Continual skill refinement through daily practice is essential, aiming maximum results with minimal invasiveness. This article examines challenging cases of percutaneous needle biopsy, biliary intervention, radiofrequency ablation, and percutaneous abscess drainage while referencing previous review articles and discusses how to succeed in these cases by employing various techniques and approaches in various image-guided procedures. This article aimed to provide interventional radiologists with a comprehensive and practical guide for enhancing their image-guided puncture techniques, ultimately leading to successful outcomes.

Computed tomography-guided percutaneous needle biopsy for middle mediastinal tumors with retroaortic paravertebral approach: A case report

A 74-year-old man was referred to our hospital for a close examination of a mediastinal mass. Contrast-enhanced CT showed a middle mediastinal tumor. We planned to perform a CT-guided percutaneous needle biopsy of the tumor using a retroaortic paravertebral approach to avoid transpulmonary puncture. A coaxial blunt-tip needle with a side hole was used to create space in the mediastinum and avoid azygos vein injury. After injecting normal saline, a blunt-tip needle was advanced through the space between the aorta and the vertebral body to the anterior surface of the tumor, and tissue was obtained. The patient was discharged the following day with no complications. For percutaneous middle mediastinal tumor biopsy, the retroaortic paravertebral approach may be a safe, effective route.

Safety profile and technical success of narrow window CT-guided percutaneous biopsy with blunt needle approach in the abdomen and pelvis

OBJECTIVE

To assess success and safety of CT-guided procedures with narrow window access for biopsy.

METHODS

Three hundred ninety-six consecutive patients undergoing abdominal or pelvic CT-guided biopsy or fiducial placement between 01/2015 and 12/2018 were included (183 women, mean age 63 ± 14 years). Procedures were classified into "wide window" (width of the needle path between structures > 15 mm) and "narrow window" (≤ 15 mm) based on intraprocedural images. Clinical information, complications, technical and clinical success, and outcomes were collected. The blunt needle approach is preferred by our interventional radiology team for narrow window access.

RESULTS

There were 323 (81.5%) wide window procedures and 73 (18.5%) narrow window procedures with blunt needle approach. The median depth for the narrow window group was greater (97 mm, interquartile range (IQR) 82-113 mm) compared to the wide window group (84 mm, IQR 60-106 mm); p = 0.0017. Technical success was reached in 100% (73/73) of the narrow window and 99.7% (322/323) of the wide window procedures. There was no difference in clinical success rate between the two groups (narrow: 86.4%, 57/66; wide: 89.5%, 265/296; p = 0.46). There was no difference in immediate complication rate (narrow: 1.3%, 1/73; wide: 1.2%, 4/323; p = 0.73) or delayed complication rate (narrow: 1.3%, 1/73; wide: 0.6%, 1/323; p = 0.50).

CONCLUSION

Narrow window (< 15 mm) access biopsy and fiducial placement with blunt needle approach under CT guidance is safe and successful.

CLINICAL RELEVANCE STATEMENT

CT-guided biopsy and fiducial placement can be performed through narrow window access of less than 15 mm utilizing the blunt-tip technique.

KEY POINTS

• A narrow window for CT-guided abdominal and pelvic biopsies and fiducial placements was considered when width of the needle path between vital structures was ≤ 15 mm. • Seventy-three biopsies and fiducial placements performed through a narrow window with blunt needle approach had a similar rate of technical and clinical success and complications compared to 323 procedures performed through a wide window approach, with traditional approach (> 15 mm). • This study confirmed the safety of the CT-guided percutaneous procedures through < 15 mm window with blunt-tip technique.

Facilitating combined biopsy and percutaneous microwave ablation of pulmonary ground-glass opacities using lipiodol localisation

OBJECTIVES

Whether preoperative localisation is necessary and valuable for the microwave ablation (MWA) of small pulmonary lesions with ground-glass opacity (GGO) remains unclear. This study aimed to explore the role of the Chiba needle and lipiodol localisation techniques in facilitating MWA and biopsy.

METHODS

This retrospective before-after study included patients with GGOs who underwent conventional MWA and biopsy treatment in our hospital between January 2018 and December 2019 (group A) or who underwent the Chiba needle and lipiodol localisation treatment before MWA and biopsy between January 2020 and December 2020 (group B). The characteristics of each patient and GGO lesion were collected and analysed to evaluate the safety and effectiveness of the localisation technique.

RESULTS

A total of 122 patients with 152 GGOs and 131 patients with 156 GGOs underwent MWA and biopsy in groups A and B, respectively. The primary technique efficacy rate of MWA differed significantly between the two groups (A vs. B: 94.1% vs. 99.4%; p = 0.009). The positive biopsy rate in the two groups was determined by the difference (A vs. B: 93.4% vs. 98.1%; p = 0.042). The incidence of complications did not increase in group B.

CONCLUSIONS

Compared with the unmarked group, the Chiba needle and lipiodol localisation technique improved the positive rate of biopsy and the initial effective rate of MWA, without significantly increasing the complication rate.

KEY POINTS

• The localisation of the Chiba needle and lipiodol could improve the positive biopsy rate and the initial effective rate of MWA. • The localisation of the Chiba needle and lipiodol does not affect the subsequent MWA and biopsy and does not increase the incidence of pneumothorax and haemorrhage.

A novel core biopsy needle with shorter dead space for percutaneous image-guided musculoskeletal biopsies - how does it compare with an established core biopsy needle?

PURPOSE

To compare diagnostic yield and utility of a novel core biopsy needle (NCBN) with shortened tip dead space for percutaneous musculoskeletal biopsies with an established core biopsy needle (ECBN).

METHODS

This study was IRB approved and HIPAA compliant. All percutaneous biopsies using an NCBN performed between July 2020 and August 2021 were retrospectively reviewed. Data on patient demographics, biopsy technique, biopsy needle, and histopathology were collated.

RESULTS

Thirty-six patients were included in this study, 16 (44%) undergoing biopsy with both an NCBN and an ECBN, and 20 (56%) with an NCBN only. All 36 NCBN biopsies were 16 gauge. Fifteen (94%) of the ECBN biopsies were 14 gauge, and 1 (6%) was 16 gauge. Thirty-four (94%) of the NCBN and 15 (94%) of the ECBN biopsies were diagnostic. No adverse events were identified.

CONCLUSION

Both the NCBN and ECBN have high diagnostic rates. No adverse events were identified. NCBN could be considered for biopsy of lesions limited by anatomic location or near adjacent critical structures.

Accessing Intraabdominal Abscess for Percutaneous Drainage Using a Trocar Only Technique to Maneuver Intervening Bowel

Conventional approaches to the drainage of abscess surrounded by bowel contraindicate percutaneous drainage and often involve more invasive laparotomy. We attempt to demonstrate the use of an image-guided blunt trocar to navigate obstructive bowel and access abdominal abscess. This report presents the use of a blunt trocar to safely maneuver obstructive bowel and perform successful percutaneous drainage of intraabdominal abscess in two separate cases: one presenting a left lower quadrant diverticular abscess and the other presenting an abscess in the right lower quadrant. Thus, traversing obstructive bowel using a blunt trocar under computed tomography-guidance allows for percutaneous drainage of an intraabdominal abscess, and provides a safer and more effective alternative to more invasive procedures.

Cervical spine tenosynovial giant cell tumor involving the atlantoaxial joint in a pediatric patient with medulloblastoma

Tenosynovial giant cell tumor (TGCT) is a benign condition that arises from tendon sheaths, synovium, or bursae and is classified according to the site of involvement (intra-articular versus extra-articular) and pattern of growth (localized versus diffuse). The diffuse form tends to present as peri-articular masses and are locally aggressive. It usually presents as a mono-articular process affecting larger joints. Spinal involvement is extremely rare, particularly the cervical spine. In this case report, we present a pediatric case of spinal TGCT involving the C1-C2 joint which was incidentally detected in a 13-year-old girl undergoing surveillance for medulloblastoma recurrence. Although spinal TGCT is a benign condition, it remains a diagnostic challenge, which specific to our case can raise the concern for malignancy or metastasis. We also described a percutaneous biopsy approach using a spring-loaded blunt tip coaxial needle to avoid inadvertent vascular injury. The imaging features of spinal TGCT and biopsy approach for atlantoaxial lesion are discussed together with a comprehensive review of the literature.

Technical safety and efficacy of a blunt-tip microwave ablation electrode for CT-guided ablation of pulmonary ground-glass opacity nodules

OBJECTIVES

To evaluate the safety and technical efficacy of a customized blunt-tip microwave ablation (MWA) electrode for CT-guided ablation of pulmonary ground-glass opacity nodules (GGOs).

MATERIALS AND METHODS

This was a retrospective before-after study. All consented patients with GGOs who underwent MWA treatment using conventional sharp-tip electrodes (group A) between January 2018 and December 2018 or new blunt-tip electrodes (group B) between January 2019 and December 2019 in our institution were included. The individual features of each patient and lesion, as well as technical and clinical information, were collected and analyzed.

RESULTS

Sixteen (7 males, 9 females; mean age, 64.9 ± 12.3 years) and twenty-six (11 males, 15 females; mean age, 66.5 ± 10.7 years) patients were enrolled in groups A and B, respectively. The technique was successfully performed in all patients and a follow-up CT scan at 24 h after MWA showed that the technical efficacy rate was 100% in both groups. Twelve (75.0%) grade I complications were noted in group A, whereas 11 (42.3%) were noted in group B (p = 0.039, chi-square test). No bleeding occurred within the lesions in group B.

CONCLUSIONS

The blunt-tip MWA electrode is a safe and technically effective tool for ablating GGO lesions.

KEY POINTS

• A new blunt-tip MWA electrode was used for CT-guided ablation of GGO lesions. • The blunt-tip MWA electrode could improve the safety of GGO ablation. • The technical efficacy of ablation was maintained by using the blunt-tip MWA electrode.

Musculoskeletal interventional oncology: current and future practices

Management of musculoskeletal (MSK) tumours has traditionally been delivered by surgeons and medical oncologists. However, in recent years, image-guided interventional oncology (IO) has significantly impacted the clinical management of MSK tumours. With the rapid evolution of relevant technologies and the expanding range of clinical indications, it is likely that the impact of IO will significantly grow and further evolve in the near future.

In this narrative review, we describe well-established and new interventional technologies that are currently integrating into the IO armamentarium available to radiologists to treat MSK tumours and illustrate new emerging IO indications for treatment.

Safety and efficacy of ultrasound-guided percutaneous coaxial core biopsy of pancreatic lesions: a retrospective study

BACKGROUND AND OBJECTIVE

Pancreatic cancer tumors are difficult to access for biopsy. The use of coaxial needles during ultrasound (US)-guided coarse needle biopsy (CNB) may help to improve specimen collection yields and avoid tissue damage. In this retrospective study, the safety, efficacy, and clinical benefits of US-guided percutaneous coaxial CNB of pancreatic masses were evaluated and compared to those of non-coaxial CNB.

METHODS

A total sample of 220 biopsies performed from August 2015 to August 2019 were analyzed, including 114 performed with a coaxial needle (17-gauge coaxial coarse needle combined with an 18-gauge coarse biopsy needle) and 106 performed with a non-coaxial needle (18-gauge coarse biopsy needle without a coaxial sheath). The coaxial CNB group was stratified by lesion location to further evaluate the applicability of coaxial core needles. The satisfactory specimen rate, diagnostic efficiency, operating time, and complication rate were compared statistically between groups and subgroups.

RESULTS

Compared to the non-coaxial CNB group, the coaxial CNB group had a greater satisfactory specimen rate (98.3% vs. 92.3%; p = 0.048), a lesser mean operating time (8.9 ± 3.27 min vs. 16.8 ± 5.77 min; p < 0.001), and a lower complication rate (2.6% vs. 9.6%, p =0 .04). A better diagnostic efficiency was obtained for coaxial CNBs in the head of pancreas (98.7%) than in the body or tail of the pancreas (90%, p = 0.047).

CONCLUSION

For pancreatic masses, coaxial CNB can yield a higher satisfactory sample rate, lower complication rate, and shorter operating time than non-coaxial biopsy. US-guided percutaneous coaxial CNB is a safe and efficient puncture technique for pancreatic lesion diagnosis.

Spinal Tumor Ablation: Indications, Techniques, and Clinical Management

Percutaneous thermal ablation has proven to be safe and effective in the management of patients with spinal tumors. Such treatment is currently proposed following the decision of a multidisciplinary tumor board to patients with small painful benign tumors such as osteoid osteoma or osteoblastoma, as well as carefully selected patients presenting with spinal metastases. In both scenarios, in order to provide a clinically effective procedure, ablation is often tailored to the specific patients' clinical needs and features of the target tumor. In this review, we present the most common clinical contexts in which spine ablation may be proposed. We scrutinize technical aspects and challenges that may be encountered during the procedure, as well as offering insight on follow-up and expected outcomes.

Performance of a New Blunt-Tip Needle for the Displacement of Critical Structure in Thermal Ablation

PURPOSE

To ascertain the performance of a new blunt-tip needle (HydroGuard^®), which allows injection of fluids during needle advancement in order to safely approach, displace and insulate nearby critical structures during thermal ablation (TA).

MATERIALS AND METHODS

This study included 27 consecutive patients treated by TA [cryoablation (CA), radiofrequency (RFA), and microwave MWA)] between April 2018 and January 2019. During TA, hydro- or gas dissection was performed with HydroGuard^® needle to displace and protect critical structures close to the tumor (< 10 mm). Technical and clinical success, distance between critical structure and tumor before and after hydro/gas dissection and complications were recorded.

RESULTS

Eighteen patients were treated by CA (66.7%), 7 by MWA (25.9%) and 2 by RFA (7.4%). Majority of patients were treated with a curative intent (24/27; 88.8%). Adjacent critical structures include vessels (n = 3), nerves (n = 10), ureter/renal pelvis (n = 3), bowel/rectum (n = 10), stomach: (n = 3), diaphragm (n = 2), and pleura (n = 1). Technical success was 100%. Clinical success was 88% (24/27). Median minimum distance to adjacent critical structures before hydro/gas dissection was 1 mm (range 0-9 mm; IQR: 0-3 mm) versus 10.5 mm (range 4-47 mm; IQR: 9.7-18 mm) after displacement. Of the 27 patients treated, four developed complications (14.8%; 95% CI: 1.4-28.2): 1 major (3.7%; 95% CI: 0-10.8) and 3 minors (11.1%; 95% CI: 0-23). Only one minor complication was related to inadequate hydro-dissection, resulting in close proximity of the critical structure to the ablation zone.

CONCLUSION

HydroGuard^® is a safe and effective needle when used to approach, displace and insulate nearby critical structures during TA.

Preclinical evaluation of the atraumatic nature of a spring loaded blunt tip coaxial needle in a swine model

PURPOSE

To test in vivo in an animal model the inherent atraumatic characteristics of the spring loaded blunt tip of a coaxial needle (Gangi-SoftGuard®, Apriomed, Sweden) against a conventional sharp stylet coaxial needle.

MATERIAL AND METHODS

The study was conducted on a 40kg male swine that was its own control for a vascular trauma model. The procedure consisted of voluntary attempts to transfix and traverse the artery/aorta under continuous real-time angiogram. Test and control needles were positioned in the region of the intercostal, superior mesenteric and femoral/deep femoral arteries, and in the aorta. Computed tomography (CT) angiogram was performed post trauma to check for bleeding in the form of extravasation of contrast material. One attempt was performed per site and needle, except for the intercostal artery where a second attempt was done with the test needle, resulting in a total of 4 and 5 tests for the control and test needles, respectively.

RESULTS

With the spring loaded blunt tip, no vascular trauma or bleeding was noted in the intercostal, superior mesenteric and femoral arteries, nor in the aorta. Vascular spasm that recovered with time was noted during the second attempt to transfix the same intercostal artery. There were consistent vascular traumas and bleedings with the control needle in all three tested arteries and the aorta, confirmed on angiogram as well as CT angiogram.

CONCLUSION

The atraumatic feature offered by the spring loaded blunt tip prevented vascular trauma during the 5 attempts made to transfix the artery/aorta in a swine.