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ECR 2019 / C-3022
Interventional radiologic procedures in thoracic infections: what every radiologist should know
Congress: ECR 2019
Poster No.: C-3022
Type: Educational Exhibit
Keywords: Thorax, Interventional non-vascular, Lung, CT, Ultrasound, Percutaneous, Abscess delineation, Drainage, Catheters, Abscess, Infection, Cavitation
Authors: D. Vas, I. Vollmer, M. Benegas Urteaga, A. Gayete, M. Sanchez; Barcelona/ES
DOI:10.26044/ecr2019/C-3022

Findings and procedure details

 

 

Bacterial infections

 

  •  FNAB can change treatment plan in cases of non-responsive pulmonary infections
  • Determination of fungal or bacterial DNA/RNA in the sample obtained by percutaneous FNAB can be helpful in immunocompromised patients

Fig. 1  Fig. 2

 

 

Nodular lung infections

 

  • In some cases, pulmonary infections can manifest as solitary or multiple nodules
  • Percutaneous image-guided biopsy can be helpful in these cases
  • It is indicated to perform more than one sample to increase the accuracy of the procedure

Fig. 3

 

 

Pyogenic pulmonary abscess

 

  • In the modern medical era is a less frequent entity and most cases are successfully treated with antibiotics.
  • When resistant to conservative treatment surgical resection was the primary election.
  • Percutaneous transthoracic tube drainage became the treatment of choice in cases of conservative treatment failure.
  • Success rate above 83.9%.
  • Complication rate 16,1 %
  • Mortality rate: 4%. Less than with surgical treatment.
  • Previously rule out central endobronchial obstructive tumour (bronchoscopy should be performed)

Drainage

 

  • Indications:

          - Size itself: greater than 4 cm,

          - Ineffective antibiotic therapy (after 10-14 days),

          - No delay in debilitated patients with poorly effective cough (e.g. in            intensive care setting) – mechanical ventilation is not a contraindication

 

  • It is important to distinguish between lung abscess and necrotizing pneumonia, as the drainage of a pneumonia could lead to a bronchopleural fistula

 

Drainage technique

 

  • US or CT guidance with Seldinger technique
  • Puncture of normal lung should be avoided if possible
  • Tube size: 6-12 F (optimal: 8F)
  • After catheter placement and fluid evacuation, irrigation with normal saline until fluid clearance and periodic irrigation with saline (5-15 ml) should be performed daily
  • The effectiveness of intracavitary fibrinolytic agents in context of pulmonary abscess has not been confirmed yet.
  • Single percutaneous aspiration and cultures of abscess content can be diagnostic and informative.

  Fig. 4 ,  Fig. 5

 

Removal:

  • Reduction in abscess size with cessation of purulent drainage for at least 3 days
  • Absence of clinical signs of sepsis

 

Complications and their management:

  • Clogging of the catheter – catheter exchange
  • Pneumothorax – chest tube insertion
  • Haemoptysis / haemothorax embolization
  • Bronchopleural fistula bronchoscopy / surgery after resolution of the infection (avoid the drainage of necrotizing pneumonia or rapidly increasing air component) 

Fig. 6

 

Fungal infections

 

  • During the post-chemotherapeutic aplastic period of hematologic malignancies
  •  After bone marrow or solid organ transplants

         - Cultures results are often negative or late

         - BAL (bronchoalveolar lavage) sensitivity to detect aspergillosis is 50%

 

The role is to:

  • confirm fungal infection 
  • differentiate between Aspergillus spp. and Mucorales
  • rule out other aetiology (tuberculosis, septic emboli, primary tumour…)

Prior to biopsy a high resolution CT should be performed in order to

  • detect findings of probable fungal infection
  • locate target lesion for percutaneous biopsy
  • guide fibroscopy and transbronchial biopsy in case of central lesions
  • detect GGO consolidations – higher sensitivity of BAL

 

 

Fungal infections – Biopsy

 

Indication:

  • Prolonged febrile neutropenia with negative BAL and cultures
  • No response to antifungal therapy

Sensitivity of FNAB or lung biopsy: 70,6% with 100% PPV.

 

Technique:

  • Biopsy needle of 18 G if possible to obtain sufficient material
  • Obtain at least 3 samples (culture, specific histological study of fungal infection and general HE stain)

   – fresh sample in dry tube for culture

   – fixed in 10% formaldehyde for histological and immunhistochemical study

  • Fixed in AFA for HES stain to rule out lesion of other aetiology.

 

Complications of FNAB of fungal infections

 

  • Pneumothorax: 17-60%, 0,5-5 % require thoracic drain insertion: ↑number of passes through the pleural cavity
  • Bleeding: 5,3 – 30 %, haemoptysis:1,25-5%, to minimize risk:

       – correct INR if exceeds 1,5 (0,8-1,2)

       – correct platelet level with transfusion below 50 000/microl         

       – suspend acetylsalicylic acid and clopidogrel 5 days before intervention            if possible

       – stop LMWH 24h before intervention

 

Fig. 2  ,  Fig. 7

 

Pleural infections

  • Pleural infections are increasing despite of modern medical therapy
  • Increased morbidity and mortality associated with pulmonary infections
  • Sampling of parapneumonic effusion with thickness greater than 10 mm (20 mm) is recommended
  • Chest X-Ray may miss 10 % of effusions with recommendation of sampling
  • Fluid pH can vary in cases of loculated effusions

  Fig. 8

 

 Indication

  

Pleural space anatomy

 

Pleural fluid bacteriology

 

Pleural fluid chemistry

Category

Risk of

poor

outcome

Drainage

A0: Minimal, free-flowing effusion (<10 mm on lateral decubitus)

and

Bx: culture Gram stain results unknown

and

Cx: pH unknown

1

Very low

NO

A1:Small to moderate free-flowing effusion (>10 mm and < one-half hemithorax)

and

B0: negative culture and Gram stain

and

C0: pH ≥ 7.20

2

Low

NO

A2: Large, free-flowing effusion (≥ one-half hemithorax), loculated effusion, or effusion with thickened parietal pleura

or

B1: positive culture and Gram stain

or

C1: pH < 7.20

3

Moderate

YES

   

B2: pus

   

4

High

YES

 

  Fig. 9

Fig. 10

  • If possible, initial thoracentesis should be therapeutic as well.•Always image guided drainage: CT or US? •US guidance permits comparison with initial findings and evaluate prognosis according to US appearance:

        - Anechoic: success rate (92,3 %), Exudative stage

        - Complex non-septated: (80-81,54%), Probably exudative stage

       - Complex septated: (50,6- 62,5%) fibrinopurulent (fibrinous adhesions             and septae)

        - organizational stages (fibrin clots, multiple septations with thick                    pleural peel): higher ICU admission rate and increased mortality rate

  • Drainage is recommended before worsening of US findings.

  Fig. 11

 

Small bore tube (6-14 F) or Large ( >20 F)?

  • Small tubes (SBCT) are as effective as large ones with the exception of acute haemothorax (or complex empyema)
  • Less complication rate with SBCT
  • Insert multiple tubes in loculated pleural effusion
  • Always with image guidance to avoid malposition (preferably US)
  • Point of insertion should be anterior to the anterior superior iliac spine line
  • LBCT in the fifth intercostal space mid axillary line with tube thoracostomy
  • SBCT typically in second intercostal space along the anterior axillary line, especially in pneumothorax
  • Place tube in dependent position for fluid drainage

 

Intrapleural fibrinolytic agents:

  • The aim is to improve the drainage of loculated pleural effusions based on observational studies.
  • Not recommended for all patients, needs to be studied in larger series.
  • Various options: Urokinase, t-PA (tissue plasminogen activator), DNase, streptokinase
  • Recent trial shows effectivity of the use of intrapleural t-PA in combination with DNase (x3 daily) but not alone:

         - improves drainage with reduction of hospital stay and minor surgical           rate.

 

 

Pleural biopsy

  • Specially indicated in suspected pleural tuberculosis
  • Definite diagnosis of pleural tuberculosis depends on the demonstration of Mycobacterium tuberculosis in the sputum, pleural fluid, or pleural biopsy specimens.
  • Image-guided pleural needle biopsy can be used as the primary method of diagnosis in patients with pleural thickening.

  Fig. 12

Fig. 13

 

Mediastinal infection

 

  • Head and neck descendent infections, trauma, foreign body, pancreatic pseudocyst, and post-operative abscess (gastro-oesophageal anastomotic leaks, cardiac surgery, thoracotomy…)
  • High rate of morbidity and mortality (20-40%), risk of re-operation
  • Few cases published, no clear guidelines for heterogeneous patient group and aetiology
  • CT guided drainage can be vital in cases of abscess formation to avoid re-operation due to its high mortality
  • Patient positioning and route planning prior to intervention is essential. If there is no pathway without passing through pulmonary parenchyma, artificial hydrothorax or pneumothorax can be useful.
  • Seldinger-technique, tandem trocar technique, fluoroscopically- guided tube drainage of the abscess

   Fig. 14 ,  Fig. 15 ,  Fig. 16 Fig. 19

 

Pericardial drainage

  • Only with image guidance (pericardiocentesis or tube pericardiostomy)
  •  Indication:

                - Purulent effusion

                - Tuberculosis

 

Approach according to the distribution of pericardial effusion:

  • Anterior
  • Subxyphoid
  • Parasternal
  • Left lateral

 

Complications:

  • Arrhythmias: need for patient monitoring and catheter removal
  • Pneumothorax / pneumomediastinum
  • Atrial and ventricular wall puncture
  • Epicardial laceration                                       
  • Coronary artery injury

                                          minimize risk with continuous image guidance

 

  Fig. 17 ,  Fig. 18

 

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