0:00

So let's discuss interabdominal biopsies and some

0:03

very procedural and procedural steps.

0:06

As I've said before preparation is never wasted and the

0:09

most important thing is that our patient be made aware

0:12

of everything that we're intending to do. This constitutes

0:15

a discussion of the risks of the procedure the

0:18

benefits anticipated for the

0:21

procedure the alternatives to the procedure and

0:24

any contingencies that could result we

0:27

want to ensure that we know exactly what could go

0:30

wrong and if it could go wrong you want to make sure that

0:33

the patient is well aware that we know what that is

0:36

and how we would manage it. Should that untoward event

0:39

occur?

0:40

That's what the patient is consenting to these include

0:43

risk of bleeding and infection and certainly

0:46

how we would manage them. Should they occur?

0:49

When it comes to assessing for coagulation risks

0:52

or quagalopathy, we

0:55

get pre procedural labs and we make sure

0:58

that we review them the INR the ptts which

1:01

is one of those lab values we

1:04

get to a lesser extent, but of course platelets count

1:07

is important.

1:09

patients that have nsaidrenal disease b u

1:12

n is something that we may consider looking at

1:15

And then we want to make sure that we're aware of.

1:18

Patients use of anticoagulants and anti-platelet agents

1:21

so that we can stop those.

1:24

Prior to the procedure to minimize risk of bleeding

1:27

in those settings aspirin and other anti-platelet

1:30

agents usually stop five to seven days before the procedure Warfarin

1:33

five to seven days usually stopped low

1:36

molecular weight Heparin or unfractionated usually

1:40

two to four hours prior to procedure given the

1:43

half-life of Papyrus two hours and Saint usually

1:46

stop three days before the procedure.

1:49

When we're preparing the site, it's important to be mindful

1:52

of what we're doing here. We're swabbing the

1:55

procedural side with the cross hatch configuration

1:58

prior to Preparing the patient

2:01

for biopsy. So this is particularly important to

2:04

show we have a nice antiseptic feel.

2:07

In order to minimize the risk of infection 1%

2:10

or 2% lidocaine is important to

2:13

achieve the local dermal anesthesia needed

2:16

to ensure that we don't incite any

2:19

pain in the patient When approaching

2:22

these biopsies.

2:24

We consider coaxial guidance something that

2:27

is particularly important for a number of different reasons to

2:30

ensure that we're sticking the patient once

2:33

when we cross the skin into the abdomen and that

2:36

we have a introducer in place through

2:39

which we can perform multiple biopsies. This is

2:42

good from the risk of bleeding standpoint because once

2:45

we cross the area, we don't have to Traverse it again, and then

2:48

also from a track seating standpoint, we can keep our introduced

2:51

in place and biopsy from that location.

2:54

When it comes to the different biopsy approaches, we

2:57

have to core needle biopsy which is the preferred option. It gives

3:00

us great accurate samples and

3:03

when it comes to omental or

3:06

mesenteric masses particularly helpful, this

3:09

allows us to get solid large

3:12

cores whether that be

3:15

an 18 gauge or 20 gauge course when these are

3:18

areas that are not in proximity to clinical vascular structures

3:21

would be this occasions in which we would employ them because

3:24

if there were critical vascular structures, you may

3:27

consider an alternative which we'll discuss in a second.

3:31

And that alternative is to find needle aspiration if there's any

3:34

concern for blood vessels or bleeding. We

3:37

may want to actually take an introduce

3:40

her and then actually use a smaller gauge 20 gauge

3:43

or less size needle in order to sort

3:46

of agitate the tissues in order to minimize risk

3:49

of injuring those Regional blood vessels. What

3:52

we do know is that the final aspiration really does

3:55

not allow us to maintain the cellular side of

3:58

architecture, right? And so those are the cases in which we want to get the

4:01

Cornell biopsy, but that being said there are the reasons why

4:04

we would use the final aspiration and these would be lesions

4:07

that are cystic. For example, we Center our needle directly in

4:10

Ash create that fluid send it off a psychology

4:13

analysis, maybe a small lesion a little harder for

4:16

us to get a large needle or small engage into that

4:19

lesion and if there's abscesses which

4:22

would allow us to get into that abscess, which may be

4:25

in the setting of now so malignancy which to

4:28

prevent spillage out into the

4:31

area causing seating and so in this particular setting we would just

4:34

send our needle introduce a needle just shy of the area of

4:37

concern and then FNA across the

4:40

wall of that lesion, which me actually be walling

4:43

off an abscess which could be in Walled off

4:46

The Chronic fluid in the setting of a malignancy that's

4:49

actually necrotic. And so finally aspiration would

4:52

be particularly good in that setting to minimize risk of seeding.

4:56

It's important to understand how we localize our

4:59

biopsy targets either. We're using CT

5:02

guidance or ultrasound guidance. I would have mentioned and really

5:05

that depends on the operate experience and comfort level.

5:08

It also depends on the target side as we would have sort of

5:11

outlined in the advantages versus disadvantages of both

5:14

modalities.

5:16

So when we have the ultrasound it's important to know that we have

5:19

the grayscale to localized lesions. But what else

5:22

do we have? We have colored Doppler and that color Doppler

5:25

flow analysis allows us to avoid major vessels

5:28

and sometimes smaller vessels that are important. That

5:31

is a particularly helpful tool when it comes to CT

5:34

guidance. We want to consider this

5:37

because it can allow us to advance our biopsy

5:40

needle using CT fluoroscopy and

5:43

a sequential fashion with appreciation of the regional anatomy

5:46

because we're viewing it on cross section with these

5:49

intermittent scans in order

5:52

to confirm appropriate trajectory.

5:55

So question for you, so when performing percutaneous biopsy

5:58

by an anterior abdominal approach?

6:01

Which superficial vessels must be avoided by the IR is it

6:04

the superior messengeric artery. Is it the

6:07

inferior mesenteric artery?

6:09

Is it the aftergastric artery or arteries?

6:12

Or is it the gastropylic artery?

6:16

And see epigastric arteries here. We have

6:19

images of the infrastracastric artery

6:22

emanating from the external iliac artery

6:25

on both sides the bilateral Superior and

6:28

inferior epigastric arteries provide blood supply to the entry abdominal

6:31

wall and they can actually be potential sites of injury in

6:34

percutaneous biopsies. Hence the branching

6:37

pattern which we want to be mindful of as we move forward.