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Imaging Guided Thoracic Interventions Black plate 507,1) Copyright #ERS Journals Ltd 2001 Eur Respir J 2001; 17: 507±528 European Respiratory Journal Printed in UK ± all rights reserved ISSN 0903-1936 SERIES "THORACIC IMAGING" Edited by P.A. Gevenois and A. Bankier Number 1 in this Series Imaging guided thoracic interventions B. Ghaye, R.F. Dondelinger Imaging guided thoracic interventions. B. Ghaye, R.F. Dondelinger. #ERS Journals Dept of Medical Imaging, University Ltd 2001. Hospital Sart Tilman, LieÁge, Belgium. ABSTRACT: Interventional Radiology is a technique based medical specialty, using all available imaging modalities ¯uoroscopy, ultrasound, computed tomography, magnetic Correspondence:B. Ghaye, Dept of Medical Imaging, University Hospital resonance, angiography)for guidance of interventional techniques for diagnostic or Sart Tilman B 35, B-4000 LieÁge, therapeutic purposes. Belgium. Actual, percutaneous transthoracic needle biopsy includes core needle biopsy besides Fax:32 43667772 ®ne needle aspiration. Any pleural, pulmonary or mediastinal ¯uid or gas collection is amenable to percutaneous pulmonary catheter drainage. Keywords:Arteries Treatment of haemoptysis of the bronchial artery or pulmonary artery origin, interventional radiology transcatheter embolization of pulmonary arteriovenous malformations and pseudoa- stents neurysms, angioplasty and stenting of the superior vena caval system and percutaneous therapeutic blockade thorax foreign body retrieval are well established routine procedures, precluding unnecessary transthoracic biopsy surgery. These techniques are safe and effective in experienced hands. Computed tomography is helpful in pre- and postoperative imaging of patients being Received:October 10 2000 considered for endobronchial stenting. Many procedures can be performed on an Accepted after revision December 27 outpatient basis, thus increasing the cost-effectiveness of radiologically guided 2000 interventions in the thorax. Eur Respir J 2001; 17: 507±528. Percutaneous nonoperative procedures in the chest wing the description of "arti®cial pneumomediastinum" were applied before the advent of imaging. LEYDEN [1] [6]. A rigid cystoscope was introduced by NordenstroÈm performed the ®rst transthoracic needle lung biopsy in in the mediastinum under combined ¯uoroscopic and 1882 to con®rm pulmonary infection. During the ®rst direct vision control ENordenstroÈm, Karolinska Hospi- half of the twentieth century, lung biopsy was mainly tal, Stockholm, Sweden; personal communication). used to establish the microbiological diagnosis of ex- Percutaneous mediastinal puncture however, was not tensive infectious lobar consolidation, which was easy widely carried out before the advent of CT with reduced to localize. Percutaneous needle sampling in the chest scanning times. Percutaneous insertion of drainage however, fell into disrepute, due to an unacceptable catheters in ¯uid collections of the pleura, lung or high rate of complications, caused by the large calibre mediastinum, guided by ¯uoroscopy or CT was of needles. Despite the use of smaller needles, patho- introduced in the late seventies using basic catheter- logists remained reluctant to formulate a diagnosis on guidewire techniques, which were applied already in the small samples or smears. Fluoroscopically guided bron- abdomen [7]. Arteriography of the bronchial arteries chial brush biopsy was described in the sixties [2]. At the was also described in Sweden in the sixties. Chemo- same time, the innovating work of NORDENSTROÈ M and infusion in bronchomediastinal arteries for treatment of ZAJICEK [3] at the Karolinska Hospital in Stockholm inoperable bronchial carcinoma was the ®rst clinical popularized the technique of transthoracic ®ne needle application of vascular interventional techniques in the sampling in the chest. The rate of pneumothorax was chest, but was not widely spread [8]. Catheter dramatically reduced with the systematic use of small embolization of bronchial or systemic arteries for gauge needles, although the rate of inadequate cellular treatment of haemoptysis was introduced in the next material or false negative diagnoses in the con®rma- decade [9]. Miniaturization of catheters and re®nement tion of malignancy persisted in the 15±25% range. False in embolic agents de®nitely established bronchial artery positive diagnoses did not exceed 2%. Transthoracic embolization as an accepted technique. Similar vascular needle biopsy of mediastinal lymph nodes was des- occlusion techniques were applied in pulmonary cribed by a transjugular, a paraxiphoid or a paraver- arteries, ®rst for treatment of haemoptysis, then as a tebral approach [4, 5]. These transthoracic approaches means of occlusion of pulmonary arteriovenous ®stula, were adopted on a routine basis, when computed to- with coils or detachable balloons [10, 11]. mography ECT) became available. Mediastinoscopy When adequate vascular catheters, wires and was also developed at the Karolinska Hospital, follo- other devices, such as snare loops became available, Black plate 508,1) 508 B. GHAYE, R.F. DONDELINGER percutaneous foreign body retrieval from the heart or availability in radiological departments. Fluoroscopy pulmonary arteries became applicable [12]. The intro- allows adjustment of the tip of a catheter previously duction of expandable metal vascular stents further inserted into a ¯uid collection with ultrasonography broadened the spectrum of closed minimally invasive EUS) or CT control [28]. Opaci®cation of ®stulous techniques in the chest, allowing for minimally invasive tracts is best documented with ¯uoroscopy and plain treatment of superior vena cava ESVC) obstruction with ®lms, in some occasions in combination with CT. an immediate clinical result [13]. The most prominent interventional radiological techniques in the chest mentioned earlier will be discussed in this paper. Computed tomography CT offers exquisite anatomical display of all the thoracic structures and allows percutaneous access to Percutaneous nonvascular interventions all spaces with equal ease [14, 19±23, 28±33]. Intrave- nous contrast medium injection is mandatory for The various percutaneous nonvascular applications identi®cation of necrosis, ¯uid content, normal vascular that are in clinical use in the authors9 department are structures and false aneurysm located in an abscess listed in table 1. wall, and also contributes to a precise delineation of a lesion with regard to the anatomical environment. CT is particularly useful for guiding puncture of a mediastinal Imaging guidance modalities lesion and an intrapulmonary lesion that is dif®cult to localize with ¯uoroscopy alone [29, 34]. CT allows for Imaging techniques used for the guidance of inter- determination of an optimal cutaneous entry point in ventional procedures include ¯uoroscopy and cross- such a way as to avoid transgression of a pleural ®ssure section imaging or a combination of both [14]. A or puncture of large vessels, bronchi and the oesopha- comparison of the different imaging modalities for gus. The spiral scanning capability was not proved percutaneous biopsy or drainage of thoracic lesions is superior to sequential scanning [35]. Real time CT given in table 2. E¯uoro-CT or continuous CT) is now widely available and combines the advantages of cross-section imaging and real time control of the procedure [36, 37]. Fluoroscopy Uni- or bi-planar ¯uoroscopy was the ®rst technique Ultrasonography to be used as a guidance of percutaneous transthoracic Apart from it being the primary imaging guidance needle biopsy ETNB) and drainage of ¯uid collections for biopsies of the chest wall or pleural lesions as well as [3, 16±27]. Advantages are familiarity to most opera- lesions located in the anterior mediastinum [38, 39], tors, real-time control of the procedure, and its wide ultrasonography EUS) is particularly indicated to guide bedside percutaneous aspiration and catheter drainage Table 1. ± Percutaneous imaging guided nonvascular interventions in the thorax of a pleural or pericardial ¯uid collection, even of only small amounts [19±22, 28, 40±43]. A subpleural pul- Frequent monary effusion and some pulmonary lesions with a Fine needle biopsy or ¯uid aspiration in the lung, pleura parietal contact can also be punctured with US con- and mediastinum trol [44±47]. The percutaneous approach is performed Catheter drainage of pleural, lung or mediastinal ¯uid or in the patient9s position that optimally displays access air collections to the lesion. Infrequent Pre-operative localization of a lung nodule Drainage of tension mediastinum Magnetic resonance Percutaneous block of the upper sympathetic chain Brachytherapy, electrochemical or radiofrequency treat- Guidance of percutaneous interventions is a promis- ment of pulmonary malignancy* Treatment of secondary pulmonary aspergilloma* ing application of magnetic resonance EMR) [48, 49]. Little clinical experience is gained so far in thoracic *:No personal experience. interventions. Table 2. ± Comparison of imaging techniques for guidance of thoracic interventions Modality Cost Availability Radiation Length of Access to Real time Mobilization of Epatient/physician) procedure central lesion control the patient Fluoroscopy z zzz z/z z z zzz zzz CT zz zz zz/0 zzz zzz 0 z Fluoro-CT zz zz zz/z zz zzz zz z Ultrasonography z zzz 0/0 zz 0 zzz zzz MR zzz z 0/0 zzz zzz z z Modi®ed from KLEIN and ZARKA [15]. CT:computed tomography; MR:magnetic resonance. The plus symbols represent a qualitative assessment; the greater the number of plusses the greater
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