Interventional ultrasonography. Interventional ultrasound technique

This practical guide covers the full range of interventional procedures performed under ultrasound guidance used in clinical practice. The material provides comprehensive recommendations from reputable experts on performing ultrasound-guided biopsies, using ultrasound to provide access to various organs and structures, in diagnostic and therapeutic interventional procedures, installing drains, as well as in sonohysterography. Key procedures such as biopsy of the thyroid and mammary glands, superficial lymph nodes, sonohysterography, musculoskeletal and other interventions are covered in detail. A compact step-by-step presentation of the material ensures rapid assimilation, special attention is paid to indications, contraindications, equipment used, methods of implementation, subsequent examination, possible complications and their treatment. Over 600 high-quality illustrations make complex procedures easy to understand. Book...

This practical guide covers the full range of interventional procedures performed under ultrasound guidance used in clinical practice. The material provides comprehensive recommendations from reputable experts on performing ultrasound-guided biopsies, using ultrasound to provide access to various organs and structures, in diagnostic and therapeutic interventional procedures, installing drains, as well as in sonohysterography. Key procedures such as biopsy of the thyroid and mammary glands, superficial lymph nodes, sonohysterography, musculoskeletal and other interventions are covered in detail. A compact step-by-step presentation of the material ensures rapid assimilation, special attention is paid to indications, contraindications, equipment used, methods of implementation, subsequent examination, possible complications and their treatment. Over 600 high-quality illustrations make complex procedures easy to understand. The book is ideal for refreshing your knowledge before performing the procedure.
For practicing interventional surgeons, radiologists, oncologists, obstetricians-gynecologists, anesthesiologists-resuscitators, ultrasound diagnostic specialists, and trainee doctors.

Interventional radiology is a branch of medical radiology that develops the scientific foundations and clinical application of therapeutic and diagnostic procedures carried out under the control of radiation research.

The intervention consists of two stages. The first stage includes a radiation study (X-ray television scanning, computed tomography, ultrasound or radionuclide scanning, etc.) aimed at establishing the nature and extent of the lesion. At the second stage, usually without interrupting the study, the doctor performs the necessary medical procedures (catheterization, puncture, prosthetics, etc.), which are often as effective as, and sometimes superior to, surgical interventions, and at the same time have a number of advantages over them. They are more gentle and in most cases do not require general anesthesia; the duration and cost of treatment are significantly reduced; the percentage of complications and mortality are reduced. Interventional interventions can be the initial stage of preparing severely weakened patients for subsequent surgery.

Indications for interventional procedures are very wide, which is associated with the variety of problems that can be solved using interventional radiology methods. General contraindications are the serious condition of the patient, acute infectious diseases, mental disorders, decompensation of the functions of the cardiovascular system, liver, kidneys, and when using iodine-containing radiocontrast agents - increased sensitivity to iodine preparations.

Preparing the patient begins with explaining to him the purpose and methodology of the procedure. Depending on the type of intervention, different forms of premedication and anesthesia are used. All interventional interventions can be divided into two groups: x-ray endovascular and extravasal.

X-ray endovascular interventions, which have received the most recognition, are intravascular diagnostic and therapeutic procedures performed under X-ray control. Their main types are x-ray endovascular dilatation, or angioplasty, x-ray endovascular prosthetics and x-ray endovascular occlusion.

Vascular interventions.

1. Arterial angioplasty for peripheral and central vascular pathology.

This range of interventions includes balloon dilation of arteries, vascular stenting, and atherectomy. With obliterating diseases of the lower extremities, there is often a need to restore the lumen of the affected vessels in order to eliminate ischemia. For these purposes, in 1964, Dotter and Judkins began to use a set of coaxial catheters to bougienage the lumen of the arteries. But the greatest progress was made after the introduction of a special balloon catheter by Gruntzig in 1976. Inflating a balloon installed at the site of narrowing of the vessel leads to the restoration of its lumen either in full or in a size that allows adequate nutrition of the limb. In addition, there is the possibility of multiple dilations. In subsequent years, balloon dilations began to be used on brachiocephalic, coronary, renal, mesenteric arteries, and hemodialysis fistulas. However, inevitable trauma to the intima and its subsequent hyperplasia lead to a high percentage of restenosis. In this regard, intravascular metal or nitinol prostheses - stents - were developed. There are several modifications of stents, which can be divided into self-expanding and balloon-expandable. Accordingly, the method of their implantation differs. Wallstent placement is preceded by balloon dilatation, and with balloon-expandable stents this occurs simultaneously. Moreover, the use of polyethylene-coated stents allows them to be used for the treatment of aortic and large artery aneurysms (including fusiform and large aneurysms) by creating a new lumen of the vessel. In recent years, stenting of the vena cava has become used when it is compressed by tumors, as well as any hollow tubular structures, such as the esophagus, pylorus, biliary tract, intestines, trachea and bronchi, ureters, nasolacrimal duct. The main indications for such procedures are malignant inoperable tumors. Despite the palliative nature, dysphagia, esophageal-respiratory fistulas, obstructive jaundice, intestinal obstruction, and urostasis are very successfully relieved.

2. Combating pathological thrombus formation.

Regional thrombolysis has now become widely used. Installing the catheter as close as possible to the blood clot allows you to increase the efficiency and reduce the dose of fibrinolytic drugs administered through it, thereby reducing the side effects of such treatment. Some companies have developed systems for intravascular mechanical thrombus retraction and suction of fresh clots. The most effective method of combating pulmonary embolism is the installation of metal filters in the inferior vena cava. This creates an obstacle to the path of large migrating blood clots. To install the filter, either transfemoral or transjugular access is used, a special system for installing and delivering the filter. Filters vary in their modification. The most famous are the Gunther-Tulip and Bird's Nest filters from William Cook Europe, and the Greenfield filter from Medi-Tech/Boston Scientific.

3. Vascular embolization.

This type of intervention is used to stop bleeding of various locations, treat a number of tumors, as well as some aneurysms and vascular anomalies. Oil contrast agents, hemostatic gelatin sponge, Ivalon, sotradecol, 96% ethyl alcohol, metal spirals, autohemoclottes, microspheres with ferromagnetic materials, etc. are used as embolizing agents. Embolization for hemostatic purposes is very effective for gastrointestinal bleeding, severe pelvic injuries, advanced bleeding tumors of the lung, kidney, bladder and female genitalia.

The method of chemoembolization of the hepatic artery is widely used for malignant primary and metastatic liver tumors. The properties of oil contrast agents (lipiodol, etiodol, etiotrast, mayodil and iodolipol) were used here. When introduced into the hepatic artery, they penetrate and deposit in tumor tissue much more actively than in the hepatic parenchyma. Mixed with cytostatics (most often with doxorubicin), they have not only an ischemic, but also a chemotherapeutic effect. Some authors consider chemoembolization of the hepatic artery as an alternative to liver resection for solitary tumor lesions, and for multiple hepatic metastases, although palliative, it is the only way to prolong the patient’s life and its quality.

Other pathologies for which embolization is effective include arteriovenous malformations, cerebral aneurysms with a clearly defined neck, some tumors of the musculoskeletal system, and patent ductus arteriosus.

The abbreviation TIPS stands for transjugular intrahepatic portal vein shunt. The technique was proposed by Rusch to combat bleeding from varicose veins of the esophagus with portal hypertension. After puncture of the jugular vein and its catheterization, the catheter is installed in one of the hepatic veins, and then one of the branches of the portal vein is punctured with a special needle passed through the catheter. The created tunnel is expanded with a balloon catheter and stented. The result of the procedure is an artificially created porto-caval anastomosis through just one puncture hole.

5. Removal of foreign bodies.

With the help of catheters with trap loops, baskets and other devices, x-ray surgeons can correct flaws in their work or the consequences of interventions by surgeons and anesthesiologists in the form of scraps of catheters, conductors, and other foreign bodies left in the lumen of the vessels and cavities of the heart. After the foreign body is captured by the fixing element of the catheter, it is brought down into a peripheral vessel, most often into the femoral artery or vein, and removed through a small incision.

Extravasal interventional interventions include endobronchial, endobiliary, endoesophageal, endourinary and other manipulations.

Usage ultrasound for visual monitoring of needle advancement offers many advantages over other indirect visualization methods. Providing exceptional precision, interventional ultrasonography allows the needle tip to be positioned within the area of ​​diagnostic interest within a few millimeters. The ultrasound beam “cuts” the tissue into sections only a few millimeters wide.

Manipulating the tip of a metal needle under such conditions, it is possible to achieve its spatial positioning with extreme accuracy in all three planes. Ultrasound provides real-time visualization of needle progress through tissue. This allows the doctor to move the needle with high precision and avoid damage to vital structures.

Ultrasound technology differs from the currently common CT-guided needle positioning methods, in which the needle is guided only along a pre-planned path and a new x-ray image is required to change the needle position. What is unique about ultrasonic needle control? The much-needed real-time visualization of the needle becomes possible in three planes.

As a result, when using interventional Using ultrasonography, doctors have the opportunity to perform fairly fast diagnostic imaging, often with minimal time investment.

Interventional ultrasound technique

Because doctors can arbitrarily change the position of the ultrasonic sensor; they can access the area of ​​diagnostic interest from any angle. In general, ultrasound-guided needle movement should ensure that it is directed parallel to the ultrasound scanning plane. Because the equipment used for this procedure is portable, interventional ultrasonography can be performed in any clinical setting, including intensive care units and operating rooms.

IN most In some cases, the use of interventional ultrasonography is cheaper than CT control of needle location. The basic techniques used by sonographers for percutaneous, intraoperative or laparoscopic punctures are the same. Interventional ultrasonography, however, is limited in identifying structures obscured by bone, air, or gases in the intestine. Currently, most surgeons have little knowledge of ultrasonography techniques and equipment.

Positioning Techniques needles can be divided into three categories: indirect ultrasound guidance, free-hand puncture, and the use of guide devices.

Indirect ultrasonic testing used only to drain large fluid collections, such as pleural effusion. During an ultrasound performed without ensuring sterility conditions, a mark is applied to the skin with some kind of marker at the point of intended needle insertion. Then, after surgical treatment of the skin, the doctor performing the puncture intervention inserts a needle, guiding it in accordance with the data of a previously performed ultrasound. Surgeons rarely use this technique because it is not as accurate as techniques with direct control of the needle position.

To perform biopsy and percutaneous insertion procedures accurately and accurately, the highest image quality is required to guide needle insertion. Sensors play an important role here, as do modern built-in technologies in the ultrasound system to which the sensor is connected. The MyLab™ Twice eHD CrystaLine ultrasound system and SI2C41 iQprobe, designed for biopsy and percutaneous insertion, provide ergonomics and maximum image and Doppler waveform quality for accurate and reliable diagnostic and interventional procedures. The SI2C41 iQprobe is a lightweight and comfortable probe that can be held in a variety of ways. Its ergonomic design minimizes physical stress on the wrists during long interventional procedures.

The SI2C41 iQprobe is designed for biopsy and percutaneous procedures:

• Biopsy angle: 0° - 5° - 15°;
• The highest quality of images and Doppler curves;
• Contrast imaging;
• Virtual biopsy in real time;
• Virtual navigation: Fusion Imaging in real time.

Virtual biopsy

Virtual biopsy helps you perform ultrasound biopsies and interventional procedures more confidently in real time. The real needle is highlighted using a virtual needle image directly on the real-time ultrasound image. In addition, a three-dimensional display of the sensor, scanning plane, in-plane and out-of-plane needle, and trajectory to the target is created. Targets can be highlighted in color. The needle trajectory is visualized before insertion of the actual needle to plan the optimal trajectory in advance and avoid hitting vessels or structures.

IOT342: a sensor designed by a surgeon for surgeons

Esaote has developed a new generation of ultrasound probes, iQprobes, using new materials and techniques to achieve maximum resolution and image quality. The efficiency of the new iQprobe sensors, combined with a new ergonomic design, allows clinicians to conduct examinations with maximum comfort. Based on this technology, Esaote developed the IOT342, a new intraoperative probe with Tp-View for extended visibility, extended frequency range, compact design and ergonomic shape, suitable for compression studies. A sensor designed for surgeons.

Highest quality ultrasound during liver surgery

The IOT342 is a new wide-frequency transducer that allows the examination of all parts of the liver, both superficial and deep, using advanced technologies such as CnTI (contrast imaging) and ElaXto (elastosonography). The IOT342 covers a larger scanning plane than contact sensors and provides greater reading stability than convex sensors. The dimensions and ergonomic design allow for examination with tissue compression, holding the probe in different ways and examining hard-to-reach areas.

2 Infection in surgery, a problem of modern medicine. "In the structure of nosocomial infections, postoperative infections account for 12.2%. Infectious complications after planned operations - in 6.5%, after emergency - in more than 12% of cases. At the same time, purulent-septic complications are caused by 12% of deaths after planned and 27 % after emergency surgical interventions. More than 30% of all deaths in the postoperative period are associated with purulent-inflammatory processes" prof. ON THE. Efimenko (Minsk, III-International Scientific and Practical Conference Surgical Infection) November 29, 2006

3 clinical manifestations of infection according to D. Wittman: a. Inflammatory infiltration. b. Abscess. V. Sepsis. The pyogenic membrane of an abscess is the inner wall of a purulent cavity created by the tissues surrounding the source of inflammation. The presence of a pyogenic membrane - sharply from the bloodstream into the abscess cavity - however, due to the absorption of toxic products from the site of decay, the penetration of antibiotics is impaired; intoxication of the body is maintained

5 Abscesses of the abdominal cavity and pelvic cavity: causes of occurrence: localization: - postoperative complications - freely located - peritonitis - pancreatitis - genital infections - visceral - urinary organ infections - urological block - cholestasis - Crohn's disease - amebiasis (liver abscesses) - infection cyst - injury

6 Treatment of abscesses - identifying the original source of infection - prescribing effective antibiotics, - draining foci of infection. Percutaneous puncture (drainage) under ultrasound or CT control of an abscess or festering cyst - as an alternative to surgery. Major or minor surgery?

8 - liver abscesses – 12 - freely located abscesses – 67 Subphrenic - 6 Subphrenic - 6 Subhepatic - 11 Subhepatic - 11 Interintestinal - 12 Interintestinal - 12 In the bed of the removed (resected) kidney - 4 In the bed of the removed (resected) kidney - 4 In the bed removed spleen - 2 In the bed of the removed spleen - 2 Abscesses and suppurating pancreas cysts - 24 Abscesses and suppurating pancreas cysts - 24 Pelvic abscesses - 8 Pelvic abscesses kidney abscesses (suppurating cysts, suppurating hematomas) - 32 hematomas) suppurating lymphocysts for - 6 Materials and methods Over the years, 117 patients with abscesses of the abdominal and pelvic cavity were treated using interventional ultrasound, of which:

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10 Methodology The drainage procedure consists of the following stages: Preparing the patient for manipulation Selecting an acoustic window Local anesthesia Sol. Lidokaini 2% Puncture Catheterization Evacuation of contents Fixation of the catheter, ensuring outflow Sanitation and administration of a/b, a/c drugs Systemic antibiotic therapy Analysis of the dynamics of clinical symptoms, laboratory parameters, ultrasound control Removal of drainage

11 For puncture and drainage of abscesses the following were used: - puncture needles G, - stylet catheters Fr (one-step drainage) - sets of transtrocar drainage Fr - sets for drainage according to the Seldinger method. The duration of the operation was 5-15 minutes. The duration of the operation was 5-15 minutes.

15 The effectiveness of treatment was 91.5%, recovery (using only this method) - in 87.2% of cases. liver abscesses - 10 (out of 12) subdiaphragmatic - 6 (out of 6) subhepatic - 11 (out of 11) interintestinal - 10 (out of 12) in the bed of a removed (resected) kidney - 4 (out of 4) in the bed of a removed spleen - 2 (out of 2) ) abscesses and suppurating pancreas cysts - 18 (out of 24) Results

16 Results: pelvic abscesses - 8 (out of 8) suppurating kidney cysts - 28 (out of 28) kidney abscess (suppurating hematoma) - 4 (out of 4) suppurating pelvic lymphocysts - 6 (out of 6) - To sanitize the abscess, 1 to 7 punctures were required (drainage). - In 78% of cases, intoxication and fever resolved within 2-5 days. - The duration of treatment in the hospital was from 5 to 16 days, 21 patients with suppurating kidney cysts were treated on an outpatient basis. There were no complications associated with punctures and drainage.

17 Conclusions: The puncture-drainage method of treatment of abscesses under ultrasound control: - an effective method for the treatment of abscesses of the abdominal cavity and pelvis - does not require anesthesiological support - provides a high quality of life for patients - reduces postoperative complications and mortality - reduces the length of stay of patients in the hospital - is an alternative traumatic surgery or preoperative preparation stage