7/11/2011 1 Ultrasound Guided Ultrasound Guided Procedures Procedures Andrej Lyshchik, M.D., Ph.D. Interventional Radiology Fellow Department of Radiology and Radiological Sciences Vanderbilt University Medical Center Nashville, TN Background Background Technique and instrumentation Technique and instrumentation Outline Outline Clinical applications Clinical applications Future Future developements developements Sagittal image Sagittal image of normal liver of normal liver Sagittal image Sagittal image of two liver metastasis of two liver metastasis Ultrasonically Ultrasonically‐ controlled controlled fine fine‐needle needle aspiration is aspiration is more more h h l h h l accurate than the usual accurate than the usual blind procedure in the blind procedure in the diagnosis of liver diagnosis of liver metastases. metastases. Biopsy Biopsy Fluid aspiration & drainage Fluid aspiration & drainage Vascular access Vascular access Current clinical applications Current clinical applications Vascular access Vascular access Image guided treatments Image guided treatments MSK applications MSK applications Sonohysterography
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Andrej Lyshchik, M.D., Ph.D.Interventional Radiology Fellow
Department of Radiology and Radiological SciencesVanderbilt University Medical Center
Nashville, TN
BackgroundBackground
Technique and instrumentationTechnique and instrumentation
OutlineOutline
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Clinical applicationsClinical applications
Future Future developementsdevelopements
Sagittal image Sagittal image of normal liver of normal liver
Sagittal image Sagittal image of two liver metastasisof two liver metastasis
UltrasonicallyUltrasonically‐‐controlled controlled finefine‐‐needle needle aspiration is aspiration is more more
h h lh h laccurate than the usual accurate than the usual blind procedure in the blind procedure in the diagnosis of liver diagnosis of liver metastases.metastases.
Current clinical applicationsCurrent clinical applications
Vascular accessVascular access
Image guided treatmentsImage guided treatments
MSK applicationsMSK applications
Sonohysterography
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Focal nodules or masses anywhereFocal nodules or masses anywhere
Elevated LFT’sElevated LFT’s
Medical renal diseaseMedical renal disease
Biopsy Biopsy ‐‐ IndicationsIndications
Medical renal diseaseMedical renal disease
Transplant evaluationTransplant evaluation
LymphadenopathyLymphadenopathy
In spite of the dramatic improvement in In spite of the dramatic improvement in tumoraltumoraldiagnosis, diagnosis, percutaneouspercutaneous biopsy continues to be widely biopsy continues to be widely used in oncology.used in oncology.
Biopsy Biopsy ‐‐ IndicationsIndications
In patients with cancer detailed information on the In patients with cancer detailed information on the tumor molecular composition is important to support tumor molecular composition is important to support correct selection of an appropriate treatment.correct selection of an appropriate treatment.
The performance of the biopsy is limited by several The performance of the biopsy is limited by several factors, among which tumor characteristics such as factors, among which tumor characteristics such as tumor type, size and location.tumor type, size and location.
A physical examination should be done before the A physical examination should be done before the procedureprocedure
The preThe pre biopsy coagulation status should be knownbiopsy coagulation status should be known
Biopsy Biopsy ‐‐ TechniqueTechnique
The preThe pre‐‐biopsy coagulation status should be known.biopsy coagulation status should be known.
PT / PTTPT / PTT
PLTPLT
Local anesthesia / conscious sedation is indicatedLocal anesthesia / conscious sedation is indicated
Sterile fieldSterile field
Biopsy guide or free handBiopsy guide or free hand
22G to 25G for fine22G to 25G for fine‐‐needle aspiratesneedle aspirates
Biopsy Biopsy ‐‐ TechniqueTechnique
14G to 21G core biopsy needles14G to 21G core biopsy needles
Keep needle in plane of beamKeep needle in plane of beam
Always keep needle in the same plane Always keep needle in the same plane as the beamas the beam
Entry point and angle for a superficial lesion: Entry point and angle for a superficial lesion: Aim needle more parallel to the skin Aim needle more parallel to the skin
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Entry point and angle for a superficial lesion: Entry point and angle for a superficial lesion: Aim needle more parallel to the skin Aim needle more parallel to the skin
BiopsyBiopsyBiopsyBiopsy
Entry point and angle for a deep lesion: Entry point and angle for a deep lesion: Aim needle more perpendicular to the skin Aim needle more perpendicular to the skin
Entry point and angle for a deep lesion: Entry point and angle for a deep lesion: Aim needle more perpendicular to the skinAim needle more perpendicular to the skin
BiopsyBiopsyBiopsyBiopsy
Targeting of the needle in the vascular, Targeting of the needle in the vascular, viable areas of several tumorsviable areas of several tumors
Avoiding necrotic / avascular areas in largerAvoiding necrotic / avascular areas in larger
CEUS assisted biopsyCEUS assisted biopsy
Avoiding necrotic / avascular areas in larger Avoiding necrotic / avascular areas in larger tumors or in those with frequent necrosis; tumors or in those with frequent necrosis;
Targeting of otherwise invisible lesions or Targeting of otherwise invisible lesions or those hardly visible (small nodules of HCC those hardly visible (small nodules of HCC on cirrhosis, adenocarcinoma’s areas in the on cirrhosis, adenocarcinoma’s areas in the prostate)prostate)
Interventional Interventional sonographysonography is an evolving is an evolving and rapidly developing technology. and rapidly developing technology.
ConclusionConclusion
It provides unique advantages of high It provides unique advantages of high resolution, real time guidance, lower cost. resolution, real time guidance, lower cost. Thus, making it ideal guiding method in Thus, making it ideal guiding method in variety of interventional applications.variety of interventional applications.