Radiographically guided percutaneous catheter drainage of pleural fluid collections

We reviewed the outcome of guided percutaneous catheter drainage of pleural fluid collections in 18 patients over a 5-year period. Catheter positioning was guided by fluoroscopy in 10 (56%) cases, CT in seven (39%), and sonography in one (6%). Included were 16 patients with empyemas and one each with a sterile hematoma and transudate. In nine of the patients, previous surgical chest tube drainage had been unsuccessful. The majority of collections were treated with a 12- or 14-French catheter and closed underwater seal drainage. Twelve (80%) of the 15 patients who had an adequate trial of guided drainage were cured. Propyliodone oil suspension contrast sinography after catheter placement showed two clinically unsuspected bronchopleural fistulas. Although an extensive multilocular pleural collection was a contraindication to percutaneous catheter drainage, the thick fibrous peel of a chronic empyema was not. Drainage of pleural fluid collections with radiographic guidance ensures proper catheter placement and is successful in a high percentage of cases.     

Image-guided percutaneous drainage of thoracic empyema: Can sonography predict the outcome?

The aim of this study was to assess the safety and efficacy of image-guided percutaneous catheter drainage (IGPCD) of thoracic empyemas, and to correlate the outcome of IGPCD with the pre-procedural sonographic appearance. One hundred three patients (74 males and 29 females) with thoracic empyema (age range 1 month to 70 years, median age 28 years) underwent IGPCD. In 63 (61.17 %) patients, IGPCD was the primary treatment modality; in 40 (38.84 %) patients it was used after unsuccessful intercostal chest tube drainage (ICTD). Ultrasound was the main modality used for guidance; CT guidance was used in only 7 patients (6.8 %). Eight- to 12-F pigtail catheters or 10- to 14-F Malecot catheters were used. The outcome was correlated with the pre-procedural US appearance (anechoic, complex non-septated or complex septated) of the empyema. The IGPCD technique was successful in 80 of 102 patients. Based on the US appearance, IGPCD was successful in 12 of 13 (92.3 %) patients with anechoic empyemas; 53 of 65 (81.54 %) patients with complex non-septated empyemas, and in 15 of 24 (62.5 %) patients with complex septated empyemas. A statistically significant difference (p < 0.01) was seen in the outcome of IGPCD in the three categories. Twenty-two patients required further treatment: ICTD (n = 9; 2 of them later also underwent surgery); and surgery (n = 15). The duration of catheter drainage ranged from 2–60 days. No major complications were encountered. Percutaneous catheter drainage of thoracic empyemas with imaging guidance ensures accurate catheter placement with a high success and a low complication rate. Pre-procedural US can predict the likelihood of success of IGPCD. Received: 16 September 1998; Revision received: 6 January 1999; Accepted: 9 June 1999     

Sonographic guidance in diagnostic and therapeutic interventions in the pleural space

One hundred eighty-seven diagnostic and therapeutic interventional procedures in the pleural space were performed by using sonographic guidance. These consisted of diagnostic aspiration (118), drainage of malignant and nonmalignant effusions (41), empyema drainage (17), pleural sclerotherapy with tetracycline or bleomycin (7), and pleural biopsy (4). Diagnostic aspiration was performed with 20-gauge needles, and therapeutic and empyema drainages were performed by trocar technique with either a 7-French Sacks catheter or a specially designed empyema drainage catheter. Pneumothoraces were seen in 3% of the patients, and most of these were treated by the radiologist with placement of a Heimlich valve. We conclude that the use of sonography allows rapid localization of pleural fluid collections and instant monitoring of drainage of noninfected fluid collections and empyemas.     

Image-guided catheter drainage of infected pleural effusions

PURPOSE: To evaluate the safety and efficacy of image-guided drainage of infected pleural effusions. MATERIALS AND METHODS: The clinical outcomes of 93 patients who underwent image-guided drainage of infected pleural effusions between 1998 and 2003 were retrospectively analyzed. Among the 93 patients, 31 (33.3%) were younger than 16 years of age. In all, 129 catheters (8F-14F pigtail catheters) were placed under ultrasonography (US) or computed tomography guidance. In 27 patients (29.0%) intracavitary fibrinolytic therapy with streptokinase was employed to improve drainage. The patients were followed up during daily rounds and, when drainage problems occurred, catheters were exchanged or repositioned. New catheters were placed for undrained loculations. RESULTS: The success, failure, and recurrence rates were 92.5% (86/93), 7.5% (7/93), and 6.4% (6/93), respectively. In the pediatric age group the success rate was significantly higher. Intracavitary fibrinolytic therapy significantly improved daily output, but did not significantly reduce drainage duration or hospital stay. There was no significant difference between the successful and failed treatment cases in terms of US findings, gross appearance, or culture positivity. The only major complication was anaphylactic reaction due to intracavitary instillation of streptokinase (n = 1, 1.1%). The 30-day mortality rate was 2%. CONCLUSION: Image-guided catheter drainage of infected pleural collections is a safe and effective method. Addition of intracavitary fibrinolytic instillation improves drainage, but early intervention prior to collections becoming more complicated remains an important factor in determining prognosis. Non-loculated anechoic collections without septa have a high probability of favorable outcome.     

Percutaneous catheter drainage of pleural effusion and empyema

Fluoroscopy-guided percutaneous catheter drainage (PCD) was used in 38 patients to diagnose and/or treat pleural effusions (21), hemothorax (one), symptomatic malignant effusions (four), and empyemas (12). Fluoroscopic guidance combined with the use of a small needle, J-tip guide wire, and pigtail catheter made it possible to safely drain both free and loculated fluid collections, including areas with difficult access. In 11 of the 12 patients with empyema, the pus (or purulent fluid) was successfully drained using PCD. Two or more catheters were used in all but one patient. In four of the empyemas, PCD was used successfully after incomplete or unsuccessful chest tube drainage. In five, PCD was used as the sole means of drainage. In three patients, chest-tube drainage was used to drain residual (one) or recurrent (two) empyemas after PCD. The safety and relative ease of PCD makes it an attractive alternative method for closed drainage of pleural fluid collections.     

Treatment of thoracic multiloculated empyemas with intracavitary urokinase: a prospective study

The authors prospectively treated 10 consecutive patients with multiloculated empyemas with intracavitary instillation of urokinase via a percutaneous drainage catheter. Urokinase (100,000 IU) in 100 mL of 5% dextrose in water was instilled into the pleural cavity via a percutaneous drainage catheter. After overnight clamping, the catheter was opened and the empyema drained with use of negative suction (20 cm H2O). Intermittent irrigation of the catheter with normal saline was performed to prevent clogging of the catheter. Complete drainage of multiloculated empyemas was accomplished in nine patients by means of intracavitary instillation of urokinase via a single 8-F catheter. One patient showed complete drainage of multiloculated empyema, but recurrent empyema appeared in the site of a previous tube thoracostomy. A total of 100,000-700,000 IU (mean, 400,000 IU) of urokinase were needed for complete drainage in all patients. Plasminogen and fibrin degradation product levels in empyema fluid were determined before instillation of urokinase to demonstrate any fibrinolytic action. No complications occurred.     

Empyema and Effusion: Outcome of Image-Guided Small-Bore Catheter Drainage

Empyema and complicated pleural effusion represent common medical problems. Current treatment options are multiple. The purpose of this study was to access the outcome of image-guided, small-bore catheter drainage of empyema and effusion. We evaluated 93 small-bore catheters in 82 patients with pleural effusion (n = 30) or empyema (n = 52), over a 2-year period. Image guidance was with ultrasound (US; n = 56) and CT (n = 37). All patients were followed clinically, with catheter dwell times, catheter outcome, pleural fluid outcome, reinsertion rates, and need for urokinase or surgery recorded. Ninety-three small-bore chest drains (mean=10.2 Fr; range, 8.2–12.2 Fr) were inserted, with an average dwell time of 7.81 days for empyemas and 7.14 days for effusions (p > 0.05). Elective removal rates (73% empyema vs 86% effusions) and dislodgement rates (12% empyema vs 13% effusions) were similar for both groups. Eight percent of catheters became blocked and 17% necessitated reinsertion in empyemas, with no catheters blocked or requiring reinsertion in effusions (p < 0.05). Thirty-two patients (51%) required urokinase in the empyema group, versus 2 patients (6%) in the effusion group (p < 0.05). All treatment failures, requiring surgery, occurred in the empyema group (19%; n = 12; p < 0.05). In conclusion, noninfected pleural collections are adequately treated with small-bore catheters, however, empyemas have a failure rate of 19%. The threshold for using urokinase and larger-bore catheters should be low in empyema.     

Pleural effusions in lung transplant recipients: image-guided small-bore catheter drainage

PURPOSE: To assess the efficacy of treating pleural effusions in lung transplant recipients with small-bore catheter drainage. MATERIALS AND METHODS: Chest radiographs and computed tomographic (CT) scans obtained in 31 lung transplant recipients who had pleural effusions treated with catheter drainage were retrospectively reviewed. Duration of drainage and volume of fluid drained were recorded. Results were evaluated 1 and 3 months after chest tube removal. There was complete response (CR) when no pleural fluid remained, partial response (PR) when fluid remaining was less than the pretreatment level, and no response (NR) when fluid recurred to a level at or above the pretreatment level. Associations between cause of effusion (empyema, parapneumonic effusion, rejection, other), response (CR, PR, NR), and type of transplantation (unilateral, bilateral) were examined by using chi2 tests. RESULTS: Of 31 patients, 25 had bilateral effusions; eight of these 25 patients had small-bore catheters inserted bilaterally. Nine patients had multiple sequential catheter insertions. Duration of drainage ranged from 2 to 44 days (median, 6 days). Fluid output was 110-9,726 mL (median, 1,350 mL). One-month follow-up data were available for 31 of 39 treated pleural effusions: 11 (35%) had CR, 18 (58%) had PR, and two (6%) had NR (percentages do not add up to 100% due to rounding). Three-month follow-up data were available for 28 of 39 treated effusions: 22 (79%) had CR, five (18%) had PR, and one (4%) had NR (percentages do not add up to 100% due to rounding). One- and 3-month response rates, respectively, were not related to cause of effusion (P =.82 and.535) or type of transplantation (P =.568 and >.999). CONCLUSION: Small-bore catheter drainage of persistent pleural effusions in lung transplant recipients is usually successful, but drainage is often prolonged and may require multiple catheter placements.     

CT follow-up of empyemas: pleural peels resolve after percutaneous catheter drainage

In this prospective study, computed tomography (CT) was used to examine the resolution of pleural abnormalities following radiologic catheter drainage of empyemas. Ten patients with empyemas surrounded by pleural peels underwent thoracic CT scanning at 4, 8, and 12 weeks after removal of their catheter(s). The scans demonstrated extensive pleural thickening 4 weeks after catheter removal in all 10 patients. The pleural thickening had decreased 8 weeks after catheter removal. At 12 weeks, the pleura was essentially normal in four patients, demonstrated only a small area of plaque-like thickening in four patients, and was mildly thickened in two patients. This study demonstrates that the pleural surfaces have a remarkable capacity for healing after empyema drainage. The pleural peel resolves in most cases. These results suggest that decortication need not be performed routinely when such empyemas are encountered; rather, patients should be treated on an individualized basis and studied with serial CT to determine the necessity of decortication.     

Percutaneous thoracic drainage in neonates: catheter drainage versus treatment with aspiration alone

PURPOSE: To retrospectively compare thoracic drainage in neonates by using catheter and aspiration techniques. MATERIALS AND METHODS: Approval was obtained from the institutional research ethics board; informed consent from parents was waived. Retrospective review of 21 neonates (19 boys, two girls; mean gestational age, 39.3 weeks) who underwent percutaneous thoracic drainage during a 9-year period was performed. Data such as indication for drainage, type of drainage, age and weight at birth, corrected age and weight at the time of drainage, use of mechanical ventilation at the time of drainage, and outcomes were collected. Drainage was considered successful if the collection was treated without additional surgical or radiologic intervention. Fisher exact test and two-tailed unpaired student t test with a confidence level of 95% (unequal variances assumed) were used to compare neonates treated with a catheter and those treated with aspiration. RESULTS: Image-guided therapy was used to treat pleural effusion (29%, n = 6), chylothorax (24%, n = 5), empyema (19%, n = 4), pneumothorax (14%, n = 3), mediastinal seroma (10%, n = 3), and congenital cystic adenomatoid malformation (5%, n = 1). Sixteen (76%) infants were treated with catheter placement, with a success rate of 81% (13 of 16). Five (24%) infants were treated with simple aspiration with no success. The difference in success rates was significant (P = .003). There was no significant difference between the catheter placement and aspiration groups in terms of average age, average weight, and percentage dependent on mechanical ventilation. One complication (cellulitis) was directly related to catheter drainage. In cases where treatment was successful, the mean length of the chest tube placement was 13.5 days, and there were no deaths at follow-up. In cases where treatment failed, the long-term mortality rate was 50% (four of eight). CONCLUSION: Image-guided percutaneous thoracic drainage success rates are improved if drainage catheters are placed rather than if aspiration alone is performed.     

Treatment of loculated pleural effusions with transcatheter intracavitary urokinase

Surgical thoracostomy tube placement and radiologically guided catheter drainage are standard therapy for loculated pleural fluid collections. Treatment may fail if the catheter is not placed optimally within the loculation or if the fluid is hemorrhagic or fibrinous. We studied the value of transcatheter urokinase instillation in facilitating drainage of hemorrhagic or fibrinous nonhemorrhagic loculated pleural collections in 11 patients with 13 loculated pleural collections. Eight of the fluid collections were hemorrhagic, five were nonhemorrhagic. Five patients had had a thoracostomy tube placed surgically and all had had radiologically guided placement of single lumen drainage catheters managed with suction, saline irrigation, and mechanical guidewire manipulation. This therapy had failed to drain the loculations completely over an average of 10 days (range, 1-22 days). Urokinase (1000 units/ml) was instilled into the drainage catheters in 80- to 150-ml aliquots. After 1-2 hr, suction was reinstituted and the procedure was repeated. Twelve (92%) of the 13 collections were drained completely after an average of 4.3 instillations (range, three to eight instillations). Successful urokinase therapy required an average of 28 hr (range, 8-75 hr). In one case, therapy was discontinued after partial resolution for unrelated clinical reasons. There were no complications. These results suggest that transcatheter intracavitary urokinase therapy is a safe and effective method to facilitate drainage of loculated hemorrhagic or fibrinous nonhemorrhagic pleural fluid collections.     

Image-guided management of complicated pleural fluid collections

Percutaneous image-guided catheter drainage with adjunctive ICFT has become the mainstay in the treatment of complicated pleural fluid collections. There are six basic principles of image-guided drainage and ICFT that must be understood to maximize the efficacy and safety of the procedure. 1. There must be a basic understanding of why traditional nonguided thoracostomy drainage fails in a significant percentage of patients. Tube malposition relative to fluid loculations, fluid debris and viscosity, and the presence of a stage 3 pleural peel are the primary reasons for failure. Image-guided placement of drains addresses the issue of tube malposition and ICFT greatly facilitates drainage of fibrinous fluid. 2. Proper use of cross-sectional imaging is one of the keys to ultimate success. CT and ultrasound allow very accurate assessment of the underlying pathologic process and are crucial in planning the drainage procedure, guiding the actual placement of drains, and following the course and outcome of treatment. The added costs of cross-sectional imaging are more than compensated by the increase in success of the drainage procedure. 3. Aggressive catheter management is the single most important factor in success. Multiple loculations require multiple catheters for adequate drainage. Pleural adhesions may form quickly as drainage progresses leading to the formation of undrained loculations. Frequent cross-sectional imaging is needed to detect undrained loculations so that additional drainage catheters may be placed if needed. It is crucial that the drainage catheter always be properly positioned in relation to fluid loculations. 4. Intracavitary fibrinolytic therapy is a very powerful adjunctive therapy to aid in complete evacuation of fluid collections that contain fibrin nets and debris. It can also partially débride the pleural surfaces of fibrinous debris and facilitate complete re-expansion of the underlying lung. Intracavitary fibrinolytic therapy should not be used in an attempt to salvage success by a malpositioned chest tube. 5. The ultimate success of closed drainage for complicated pleural fluid collections is closely related to the age of the effusion at the time of drainage. A very high rate of clinical success may be expected when these techniques are used in the treatment of stage 2 fibrinopurulent effusions. If drainage is delayed until the third stage (fibrous pleural peel formation) then closed drainage likely will fail and a formal thoracotomy and decortication will be necessary. Experience in the literature suggests that effusions up to 4 to 6 weeks in duration may be drained successfully but those older than 6 weeks likely will have an associated pleural peel. Effective pleural drainage must be instituted early in the course of the disease process. 6. There may be significant residual pleural and parenchymal inflammatory changes after complete drainage of a stage 2 effusion. If the fluid in the pleural space has been adequately drained and the visceral and parietal pleural surfaces apposed, then the residual inflammatory pleural thickening and associated lung consolidation resolve over 2 to 4 months and pulmonary function returns to baseline. Imaging studies immediately after complete pleural drainage are not normal. These residual abnormalities should not be interpreted as evidence that open surgical drainage should have been performed. Effective closed drainage carries lower morbidity, mortality, and cost than does open surgical drainage. For radiologists and clinicians alike it does not suffice simply to place one or more thoracostomy tubes, round daily, and hope that the occasional use of fibrinolytic agents does the rest. Without a more aggressive approach to catheter position and management the efficacy is no greater than that historically seen with nonguided closed drainage and surgeons will continue to plead for earlier effective open drainage.     

超声导向下穿刺置管术的护理及潜在并发症分析

目的分析超声导向下行穿刺置管术的护理措施及潜在并发症。方法回顾性分析超声介入科行局部穿刺置管术的205例患者资料,应用描述性统计方法分析置管类型及相应护理措施及潜在并发症。结果205例行穿刺置管术患者,其中胸腔积液88例,腹腔积液51例,经皮肝穿刺胆道引流(PTCD)29例,气胸4例,囊肿15例,心包积液10例,脓肿引流8例。其中发生气胸6例,轻微出血3例,潜在并发症还包括感染、脓胸、血管或神经损伤等。结论超声引导下穿刺置管术作为一种临床普遍接受的微创介入治疗方式,仍然会发生气胸,出血,炎症等并发症。术中谨慎的操作和密切的观察是减少并发症发生的重要因素,但对于不可避免的并发症,医护人员应仔细观察并积极处理,以确保患者有效治疗。     

Image-Guided Drainage of Pericardial Effusions in Oncology Patients

The purpose of this study was to report our clinical experience with image-guided drainage of pericardial effusions in oncology patients. IRB approval was obtained for this retrospective, HIPAA-compliant study. From November 2002 to January 2008, 40 patients underwent 43 image-guided drainages of pericardial effusions. The medical records were reviewed to analyze the technical aspects of the procedures, complications, and clinical outcomes. Thirty-three pericardial drains were placed and 10 pericardiocenteses were performed. The technical success rate was 100%. Thirty-three procedures were performed under computed tomographic (CT) guidance, five under ultrasound (US) guidance, and five using both CT and US guidance. There were no technical, procedure-related complications. Delayed postprocedure complications and arrhythmias occurred in 11 cases, for an overall complication rate of 25.6%. All complications occurred in patients who had undergone drain placement. Nine patients developed new or worsening arrhythmias and six of these patients required transfer to a higher level of care or the initiation of pharmacological management. In 58.6% of drain placements, including 4 of 11 patients who developed complications, the catheter could have been removed earlier. The median overall survival was 6.47 months (95% CI: 2.37, 12.7). In conclusion, image-guided pericardial drain placement is safe and feasible. Due to the frequency of delayed postprocedure arrhythmias, follow-up monitoring in a telemetry unit is recommended. Prompt catheter removal after drainage may reduce the incidence of delayed post-catheter-insertion arrhythmias.     

Image guided percutaneous splenic interventions

AIM: The objective of this study is to evaluate the efficacy and safety of image-guided percutaneous splenic interventions as diagnostic or therapeutic procedures. MATERIALS AND METHODS: We performed a retrospective review of our interventional records from July 2001 to June 2006. Ninety-five image-guided percutaneous splenic interventions were performed after informed consent in 89 patients: 64 men and 25 women who ranged in age from 5 months to 71 years (mean, 38.4 years) under ultrasound (n=93) or CT (n=2) guidance. The procedures performed were fine needle aspiration biopsy of focal splenic lesions (n=78) and aspiration (n=10) or percutaneous catheter drainage of a splenic abscess (n=7). RESULTS: Splenic fine needle aspiration biopsy was successful in 62 (83.78%) of 74 patients with benign lesions diagnosed in 43 (58.1%) and malignancy in 19 (25.67%) patients. The most common pathologies included tuberculosis (26 patients, 35.13%) and lymphoma (14 patients, 18.91%). Therapeutic aspiration or pigtail catheter drainage was successful in all (100%) patients. There were no major complications. CONCLUSIONS: Image-guided splenic fine needle aspiration biopsy is a safe and accurate technique that can provide a definitive diagnosis in most patients with focal lesions in the spleen. This study also suggests that image-guided percutaneous aspiration or catheter drainage of splenic abscesses is a safe and effective alternative to surgery.     

深静脉导管与输液袋结合进行胸腔积液引流的优点

目的探讨应用深静脉导管与输液袋结合进行胸腔积液引流的优点。方法对38例胸腔积液患者,应用胸腔内留置深静脉导管接一次性输液袋进行引流,并评价引流效果。结果 33例胸腔积液引流彻底,肺组织复张,未出现与操作相关的并发症,3例因感染出现脓胸,导管堵塞,改为传统的胸腔闭式引流,2例出现血气胸、血凝块,请胸外科行手术治疗。结论掌握好适应证后,深静脉导管连接输液袋引流胸腔积液是安全有效切实可行的。     

Use of a newly designed multifunctional coil catheter for stent placement in the upper gastrointestinal tract

PURPOSE: To evaluate the usefulness of a newly designed multifunctional coil catheter for stent placement in patients with upper gastrointestinal tract strictures. MATERIALS AND METHODS: Constructed in our research laboratory, the coil catheter was used in 202 consecutive patients with malignant (n = 191) or corrosive (n = 11) upper gastrointestinal tract strictures. The coil catheter was made of a stainless-steel coil (1.3-mm inner diameter, 1.8-mm outer diameter), a 0.4-mm nitinol wire, a polyolefin tube, and a hemostasis valve. Usefulness of the coil catheter was evaluated based on whether the coil catheter could pass the stricture over a guide wire and whether measurement of the stricture length was possible while the guide wire was in place. RESULTS: The passage of the coil catheter over a guide wire beyond the stricture was technically successful and well tolerated in 199 of 202 patients (99%). Negotiation of a guide wire or a coil catheter through the stricture of the stomach (n = 2) or duodenum (n = 1) under fluoroscopic guidance failed in three patients. In two of these three patients, it was possible to negotiate a guide wire and a coil catheter under combined endoscopic and fluoroscopic guidance; it was not possible in the third. There were no procedure-related complications. CONCLUSION: The newly designed multifunctional coil catheter is useful in stent placement in patients with upper gastrointestinal tract strictures.     

Radiologically-guided catheter drainage of intrathoracic abscesses and empyemas

Radiologically guided percutaneous catheter drainage was used in 38 patients to treat pleural empyemas (35 patients) and pulmonary abscesses (3 patients). Drainage was successful in 85.7% of empyemas including 11 cases with fistulous communications. Three percutaneously drained pulmonary abscesses required subsequent lobectomy. One patient died during the drainage procedure due to sepsis. No major complications related to the drainage procedure were observed. Guided percutaneous drainage proved to be a safe and successful alternative to closed drainage of pleural fluid collections. Correspondence to: H. Berger     

Radiologically-guided percutaneous catheter drainage of empyemas

We describe our experience with the percutaneous drainage of empyemas in 20 patients, using fluoroscopic, computed tomographic or ultrasonic guidance for catheter placement. The patients were seen over a period of 17 months. Sixteen patients were successfully treated, with the empyema drained and the cavity closed. In four patients drainage was unsuccessful and surgery was required. In three of these patients there was a history of illness in excess of 4 weeks preceding treatment and in one a history of trauma. Two or more catheters were used in seven patients and positive microbiological culture of the pus was obtained in 12, although neither factor significantly altered prognosis. There were no complications of the procedure. We believe the percutaneous insertion of catheters using suitable imaging guidance should be the initial method of drainage of empyemas.     

Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters.

Pleural sclerosis after drainage with a small-bore catheter was performed in 21 patients with malignant pleural effusions. Intrapleural catheters 7- to 24-French in size were placed by using sonographic guidance. Tetracycline (18 patients) and bleomycin (four patients) were used as sclerosing agents (one patient had both). Clinical and radiologic follow-up was available on all patients until they died (range, 2 weeks to 25 months; mean, 3.6 months). Pleural sclerosis was successful in 15 (71%) of 21 patients. Two patients in whom pleurodesis failed had pleural sclerosis repeated, with one success and one failure. All of the failures were in patients in whom the amount of chest-tube drainage was more than 100 ml/day. Pleurodesis with tetracycline was painful in six patients; no pain was associated with use of bleomycin. Small pneumothoraces developed in four patients at the time of chest-tube placement, without consequence. A superimposed infection that developed in a patient having continuous drainage of pleural fluid was successfully treated with antibiotics. Pleural sclerotherapy can be performed through sonographically placed small-bore catheters with results comparable to those seen with large-bore, surgically placed catheters.