Intercostal-space nephrostomy for percutaneous stone removal

Intercostal-space nephrostomies were created in 50 kidneys for removal of 17 staghorn, 9 calyceal, and 24 ureteral calculi. Complications were encountered in six [12%] of 50 patients. These included large pleural effusions in four patients and hydropneumothoraces in two patients. Four patients (8%) had chest tubes placed. The intercostal approach provides direct, straight access to both upper-pole and ureteral calculi as well as to the major portion of most staghorn calculi. Although the morbidity rate is slightly higher than for the more traditional approach via the subcostal lower pole or middle calyx complications generally can be avoided by using a working sheath and placing a large nephrostomy tube after the procedure.     

Serious complications following transgression of the pleural space in drainage procedures

Transgression of the parietal pleura may occur during placement of interventional drainage catheters into the liver and upper abdomen, and occasionally results in lethal complications. In a review of nearly 2,000 such procedures, four deaths were found to be related directly to pleural transgression from biliary drainage. Therefore, the anatomy of the pleura pertinent to abdominal needle or catheter insertion was analyzed. In 14 cadavers examined after intercostal needle insertion into the liver, needles inserted through the 9th intercostal space or higher punctured the pleura in all but one cadaver. Radiologic studies of 15 clinical cases revealed that elderly patients rarely depressed the diaphragm below the 9th intercostal space, which increases the risk of unsuspected puncture of the pleura. Review of clinical material revealed that diagnostic needle puncture through the parietal pleura carries far less risk than placement of a long-term drainage catheter. Methods to avoid puncture of the pleura, as well as the technical problems involved in such maneuvers, are given.     

Percutaneous drainage of subphrenic abscess: a review of 62 patients

Sixty-two patients who presented with subphrenic abscesses had the abscesses drained percutaneously. Diagnosis of a subphrenic collection was usually made with sonography. Initial percutaneous drainage was accomplished with a combination of sonography and fluoroscopic guidance. More recently (in the last 31 cases) most drainages were done with sonographic guidance alone. Successful catheter drainage was achieved in 85% with a complication rate of 4.8%. Failure of catheter drainage (defined as any patient who was not cured by percutaneous drainage alone) occurred in patients with multiple collections or in whom the primary cause of the abscess necessitated surgery, for example, perforated ulcer, acute cholecystitis. Considerations for successful drainage include understanding the anatomy of the subphrenic space, recognizing the importance of a correct access route (avoidance of the pleura and lung), and the long time necessary for adequate drainage (longer than 10 days in 60%). An angled subcostal approach to the subphrenic space was used in 56 (90%) of 62 cases. No complications occurred in this group. The one pneumothorax that occurred in the remaining six cases was a direct result of using an intercostal approach through the parietal pleura into a subphrenic collection. We conclude that percutaneous drainage is a safe and effective method of treatment of subphrenic abscesses.     

Percutaneous extraction of urinary calculi: use of the intercostal approach

The authors achieved successful percutaneous extraction of urinary calculi via an intercostal approach in 24 patients. In one patient, a large hydrothorax developed and thoracentesis was required; 2 patients had moderate and 6 minimal pleural fluid collections which did not require treatment. No patient had pneumothorax. Intercostal puncture provides direct access to the upper and middle poles of the kidney when they lie above the twelfth rib and subcostal angulation is not feasible. Such an approach is advantageous for stones in the ureter, as well as renal stones which are inaccessible from the lower pole. Fluoroscopy should be performed when planning the puncture in order to avoid the lung, and a working sheath is recommended.     

The safe intercostal approach? Pleural complications in abdominal interventional radiology

Six serious pleural complications (three empyemas, two hemothoraces, and one bilious effusion) have occurred after use of the right intercostal approach to the upper abdomen in 230 interventional radiologic procedures performed over the last 3 years. The anatomy of the pleural reflection in the right costophrenic sulcus is reviewed and correlated with a dissection study of the course of right intercostal needle punctures in three cadavers. The pleural reflection reaches the level of the 10th rib in the midaxillary line, and in the cadaver study, all 9th- 10th interspace punctures clearly traversed pleura, diaphragm, and peritoneum to reach the liver. The widely held belief among radiologists that the pleura can be deliberately avoided in transhepatic cholangiography and biliary drainage is shown to be false. It is believed that most needle punctures traverse the costophrenic sulcus, through pleura but below lung, despite the low incidence of reported pleural complications. a left subxiphoid approach avoiding the pleura is recommended in patients with abscesses, ascites, emphysema, anxiety, and, in the case of biliary drainage, benign or purely left-sided disease. When using the intercostal approach, the minimum number of needle passes, careful route planning, antibiotic prophylaxis, and postprocedural chest radiography are strongly recommended.     

Noninfectious complications of long-term central venous catheters: radiologic evaluation and management

During a 5-year period, 416 long-term double-lumen central venous catheters were inserted into 288 patients. In these patients, 106 catheter venograms and nine upper extremity venograms were performed. All studies were reviewed retrospectively to determine the nature and prevalence of noninfectious catheter-related complications, to evaluate the efficacy and safety of streptokinase therapy, and to determine if catheter venography should be performed before streptokinase therapy is started. Noninfectious complications occurred in 66 (23%) patients. Complications that resulted in catheter malfunction included deposition of fibrin around the catheter tip (formation of a fibrin sheath) in 44 (57%) instances, a constricting suture in six, abutment of the catheter tip against the venous wall in eight, catheter leak in two, and migration of the catheter completely out of the vein in three. Venous thrombosis developed in 11 patients. Treatment with low doses of streptokinase successfully relieved catheter obstruction due to a fibrin sheath in 27 (87%) of 31 instances. No bleeding complications occurred. Five patients had malpositioned catheters in the azygous, axillary, or internal jugular veins. By use of a deflector wire or snare inserted via the femoral vein, all five were relocated successfully into the superior vena cava. Recognition of noninfectious complications associated with use of long-term catheters is important for institution of appropriate therapy, which in many instances obviates removal of the catheter. Formation of a fibrin sheath in only 57% of cases of catheter malfunction provides an argument for performing catheter venography before streptokinase therapy is started. Low-dose streptokinase therapy for long-term central venous catheters occluded by a fibrin sheath is safe and efficacious.     

A new pyeloureteral drainage catheter

We describe a new pyeloureteral drainage catheter that can be used for both genitourinary tract stenting and drainage, as well as tamponade of bleeding from the renal parenchyma or subcutaneous tissue. Primary indications for the use of this catheter and recommendations on insertion techniques are presented. With the exception of one case of minor kinking of the catheter, we have had no complications or failures with this catheter. While insertion through an unprotected tissue track is somewhat difficult, we have had good success introducing the catheter through a 24-F or larger Teflon working sheath. The catheter has excellent patient retention properties. It can be converted from external to internal drainage or vice versa simply and quickly on the ward.     

Improved success of antegrade ureteral catheterization via the lower pole calix using a chuang reverse curve catheter: Technical note

Although antegrade ureteral catheterization is best approached from a middle or upper middle calix for the most favorable force vector. it is occasionally necessary to use a lower pole caliceal approach. A catheter technique is described for completing antegrade ureteral catheterization via the lower pole calix when conventional catheterguidewire combinations fail.     

A 'split-away technique' for percutaneous nephrostomy

The currently used techniques for nephrostomy sometimes fail to advance the drainage catheter through the nephrostomy track into the renal pelvis. To solve this problem a new technique has been developed. The improvement with this technique is the dilatation of the track with polypropylene dilators and a split-away sheath. The split-away sheath is threaded on the largest dilator. When the dilator is removed the drainage catheter is coaxially passed through the split-away sheath into the renal pelvis. The sheath is then removed. The technique has been used successfully in 32 patients without complications.     

Is the 10th and 11th Intercostal Space a Safe Approach for Percutaneous Nephrostomy and Nephrolithotomy?

The aim of this study was to determine the rate of complications in percutaneous nephrostomy (PCN) and nephrolithotomy (PCNL) performed through the 11th and 10th intercostal spaces using our monitoring technique and to discuss the safety of the procedure. Out of 398 PCNs and PCNLs carried out during a 3-year period, 56 patients had 57 such procedures performed using an intercostal approach. The 11th intercostal route was used in 42 and the 10th in 15 cases. One patient had two separate nephrostomies performed through the 10th and 11th intercostal spaces. The technique utilizes bi-planar fluoroscopy with a combination of a conventional angiographic machine to provide anterior-posterior fluoroscopy and a C-arm mobile fluoroscopy machine to give a lateral view, displayed on two separate monitors. None of the patients had clinically significant thoracic or abdominal complications. Two patients had minor chest complications. Only one developed changes (plate atelectasis, elevation of the hemi-diaphragm) directly related to the nephrostomy (2%). The second patient had bilateral plate atelectasis and unilateral congestive lung changes after PCNL. These changes were not necessarily related to the procedure but rather to general anesthesia during nephrolithotomy. The authors consider PCN or PCNL through the intercostal approach a safe procedure with a negligible complication rate, provided that it is performed under bi-planar fluoroscopy, which allows determination of the skin entry point just below the level of pleural reflection and provides three-dimensional monitoring of advancement of the puncturing needle toward the target entry point.     

The posterior intercostal approach for percutaneous renal procedures: risk of puncturing the lung, spleen, and liver as determined by CT

A posterior intercostal approach is commonly used for percutaneous access to the upper poles of the kidney. However, the safety of this approach with respect to puncturing the intervening lung, pleura, liver, and spleen with the needle has been inferred only from a small series of patients without regard to the degree of respiration. To determine the possibility of puncturing these structures, we performed CT at both maximal inspiration and expiration and with sagittal reconstructions in 43 (27 supine and 16 prone) randomly selected patients. With expiration, the needle path was such that there was little risk to the spleen and liver from an 11th-12th posterior intercostal approach. However, the chance of transgressing the lung with this approach to the kidney was 29% on the right and 14% on the left. If done during maximal inspiration, the lung would be in the path of the needle in most patients. With a 10th-11th rib posterior intercostal approach, the chance of puncturing the lung was excessive regardless of the degree of respiration used. Our results show that the primary risk from a posterior 11th-12th rib intercostal approach to the upper renal collecting system is puncture of intervening lung, a complication that can be expected to occur in from 14% to 29% of patients. The risks from a posterior 10th-11th rib intercostal approach appear prohibitive.     

Spiral exchange cannula for the occluded drainage catheter

A technique for exchange of occluded drainage catheters or placement of two guide wires into a target using a spiral exchange cannula is described. A spiral exchange cannula with a preloaded sheath and threads at the distal end is "screwed" into the drainage catheter, and the sheath is advanced over the catheter. This method prevents dislodgment of the drainage catheter and also permits easy catheter exchange when the lumen of the drainage catheter is occluded.     

CT-Guided Placement of a Drainage Catheter Within a Pelvic Abscess Using a Transsacral Approach

A 66-year-old man underwent CT-guided drainage catheter placement within a pelvic abscess with a diameter of 46 mm. We performed the drainage by a transsacral approach because it was considered the safest and most feasible approach. An 8G bone marrow biopsy needle was used to penetrate the sacrum to create a path for subsequent drainage catheter insertion. After withdrawal of the biopsy needle, a 6 Fr catheter was advanced into the abscess cavity through the path using the Seldinger technique. Except for bearable pain, no procedure-related complications occurred. Twenty-nine days after the placement, the catheter was withdrawn safely and the abscess cavity had shrunk remarkably.     

Ultrasound guidance for pericardiocentesis

Sonographic guidance with 41 punctures and 38 catheterizations was employed in 68 patients. The approach was either intercostal or subxiphoid. Most punctures were performed with a 1.4-mm-thick plastic-sheathed cannula after local anesthesia. Complications were observed in 7 patients. In one patient a catheter introduced with a movable core-type guidewire pierced the right ventricle wall with uneventful recovery after surgery. Intercostal drainage caused pleural pain in 2 patients, and in 2, leakage to the pleural space. Two patients with heart transplants had severe bradycardia and drop of blood pressure, one after needle drainage and the other during guidewire manipulation. Direct monitoring generally ensures a correct position of the instruments and hazards to adjacent organs can be avoided. In small effusions a simple needle aspiration with a plastic-sheathed cannula is safer than catheter drainage.     

CT引导下经臀途径引流盆腔深部脓肿

目的 评价CT引导下经臀途径引流盆腔深部脓肿的安全性和效果.方法 自2000年4月至2007年8月,12例盆腔深部脓肿患者接受了CT导向下经臀途径穿刺引流.回顾性分析患者的临床资料、置管数目、引流量、带管时间、并发症和随访结果.结果 对每例患者均成功经臀置人1根引流管,引流量30～180 ml,平均52 ml;带管6～34 d,平均11 d;无严重并发症发生.结论 CT引导下经臀途径引流盆腔深部脓肿安全可行.     

Obliterative pyelitis

A patient with severe undiagnosed and untreated pyelitis developed mural masses in the renal pelvis and in the infundibulum of the upper pole calyx. The masses were presumed to be inflammatory. The patient developed a severe stricture of the renal pelvis and complete occlusion of the upper pole calyx. This is an example of obliterative pyelitis, as described in the era before antibiotics were available.     

Complications of direct brachial artery puncture for arteriography: a comparison of techniques

Direct brachial artery puncture is used increasingly for day-case arteriography and patients with severe aorto-iliac disease. In expert hands low complication rates are reported, but the risks of brachial artery puncture may be higher when it is performed by less experienced operators. Over a 2 year period 49 direct brachial artery punctures were performed for arteriography. In 27 cases catheters were inserted directly over a guide-wire via a variable puncture site. In 22 cases catheters were inserted through an introducer sheath via a high brachial puncture. Significant complications requiring active treatment or surgical intervention occurred in three (11%) cases where direct catheter insertion was used. There were no complications when an introducer sheath was used. Percutaneous high brachial aortography using an introducer sheath is a safer technique when brachial artery puncture is performed infrequently.     

Obliterative pyelitis

A patient with severe undiagnosed and untreated pyelitis developed mural masses in the renal pelvis and in the infundibulum of the upper pole calyx. The masses were presumed to be inflammatory. The patient developed a severe stricture of the renal pelvis and complete occlusion of the upper pole calyx. This is an example of obliterative pyelitis, as described in the era before antibiotics were available.     

超声引导下经皮穿刺肾盂造瘘术的临床应用

目的 探讨超声引导下经皮穿刺肾盂造瘘(PCN)的临床应用价值.方法 总结分析2003-2010年解放军四五五医院住院就诊的72例急性上尿路梗阻患者行B超引导下经皮穿刺肾盂造瘘术的临床资料.结果 穿刺置管1次成功69例(95.8%),2次成功2例,失败1例,成功率98.6%(72/71).结论 超声引导下PCN是一项微创...     

Percutaneous transhepatic cholangiography and drainage. Risks and complications

An analysis of 237 consecutive PTC/PTD procedures revealed radiographically demonstrable complications in 21 per cent (50/237 cases: bile-contrast medium leakage 24 cases, haemobilia 18 cases) and clinically registered complications in 11% (26/237 cases: bile or blood leakage with or without peritonitis in 10 cases). Two deaths occurred. When possible, a drainage catheter was inserted for decompression. This was performed on 184 occasions in 139 patients--failure rate was 5 per cent. Unsuccessful attempt to introduce a drainage catheter constituted a major complication risk occurring in 5/13 cases (38%). Signs of infection were frequent though these complications were not a major problem in this series. Various possibilities to reduce complications and infections are discussed.