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397
Technical
Note
I A New Percutaneous Procedures Garey
Access
Set for Interventional
L. McLelIan1
Image-guided percutaneous interventional procedures have been enhanced by the development of introducer systems and techniques that permit safe, small-needle, single-puncture access into the renal collecting system, biliany tree, or abscess cavity [1 , 2]. The development of double-guidewine techniques and equipment for the placement of a safety and working guidewine has further facilitated the procedures, ensuning site access, especially in complex or difficult cases [3, 4]. Although these developments have aided in the performance of percutaneous procedures, they do not provide a means of directly manipulating the introducer catheter selectively into a ureter, bile duct, on abscess track. Often a series of catheter and guidewine manipulations are necessary to achieve the desired guidewine and catheter placement. The ability to place the introducer catheter and primary guidewine selectively may eliminate the need for these maneuvens. This paper describes a percutaneous access set that provides for the introduction of both working and safety guidewires and permits the introducer catheter to attain vanious degrees of distal curvature for selective placement of the primary guidewire and catheter.
Materials
The percutaneous in this report
a matching
cm-long
dilator
access
set (Cook
Inc.
,
Bloomington,
IN)
June 1 8, 1990:
Department
of Radiology,
accepted University
after revision of Florida
August Health
February
1991 0361-803X/91/1
with a 0.018-in.
stiffening
catheter
with
a 4.5-French
to the 4.5-French with
a 0.0i8-in.
cannula;
catheter;
end
end hole
a 7.5-French,
20-
end hole back
loaded
and a 4.5-French,
20-cm
(Fig. i).
hole
The procedure for using the access set is as follows: After the entry site is selected and prepared, make the initial puncture under fluoroscopic needle
control
is in the
with
desired
the location
21 -gauge and
trocar
the
needle.
When
is opacified,
site
pass
the
the
----
LZJ======
i4
D
=
-:3r:
-
-
-
-_
de-
Fig. 1.-Access set contains the following components: 7.5-French sheath (A), backloaded over 4.5-French introducer catheter (B), 19-gauge stiffening cannula (C), 0.020-in. malleable steering wire (D), 0.018-in. Cope mandril guidewire (E), 4.5-French fascial dilator (F), and 21-gauge trocar needle (G).
6, 1990. Science
Center/Jacksonville,
655 W. Eighth
L. McLellan. AJR 156:397-399,
catheter
steel
straight
and luer-locked fascial
40-cm-long
1 9-gauge
------
consists of a 21 -gauge, 1 5-cm trocar puncture needle; a 0.018-in. (0.046 cm), 80-cm-long, curved-tip Cope-mandril guidewire with platinum alloy spring guide; a 0.020-in. (0.051 cm), 42.5-cm-long malleable mandril steering wire with a 5-cm, right-angle
1
with
and Methods
scribed
Received
handle; a 4.5-French,
562-0397
© American
Roentgen
Ray Society
St.
,
Jacksonville,
FL 32209.
Address
reprint
requests
to G.
McLELLAN
Downloaded from www.ajronline.org by 117.253.220.249 on 10/21/15 from IP address 117.253.220.249. Copyright ARRS. For personal use only; all rights reserved
398
AJA:156,
February
1991
Fig. 2.-Demonstration of malleable steering wire with components labeled as in Fig. 1. A, Curved end of Cope wire (E) is seen cxtending from tip of 4.5-French introducer catheter (B). End of steering wire (D) has been handshaped to desired curvature. B, With Cope wire (E) and catheter (B) held in position, steering wire is placed coaxially into catheter and advanced completely to bend in wire. End of catheter and Cope wire have assumed shape of steering wire.
B
A
Fig. 3.-A, Spot radiograph shows a 21-gauge needle tip (small arrow) and proximal portion of a Cope wire (large arrow) within dilated renal pelvis. Note ureteropelvic junction (UPJ) strictures (arrowheads). B, Spot radiograph shows curve (arrowheads) introduced into catheter by placing hand-shaped steering wire into it. Cope wire (arrow) has been manipulated across LJPJ stricture. C, A spot radiograph shows curved steering wire (arrowheads) without platinum portion of cope wire (arrow) superimposed over it. D, A 0.035-in. working guidewire (arrow) has been introduced through sheath (arrowheads) adjacent to Cope wire.
0.018-in.
cases,
Cope
direct
guidewire
the guidewire
through
distally
the
needle.
to ensure
In biliary
adequate
and
renal
purchase
withdraw
the needle,
in the introducer
leaving
catheter
Place the steel cannula
within
Advance
step-off
within the site, and unlock the outer sheath from the inner catheter.
the mid-ureter or distal common duct. As there is an abrupt at the weld of the tapered mandril and spring coil portion of the guidewire, do not withdraw this area of the wire through either the needle or metal cannula because the wire could shear [5]. Then
this assembly
the wire in place.
and outer sheath and lock it in position.
Hold
the wire,
sheath
to the
over the guidewire
cannula, desired
and catheter
location.
When
into the desired
stationary, other
than
position
and advance minimal
curvature
the of
AJR:i56,
NEW
February 1991
the wire is encountered,
unlock
the steel cannula
PERCUTANEOUS
from the assembly,
hold the cannula and wire in position, and advance the catheter and sheath into position. Observing this caveat will avoid kinking of the wire. Remove the inner catheter and cannula and leave the Cope
Downloaded from www.ajronline.org by 117.253.220.249 on 10/21/15 from IP address 117.253.220.249. Copyright ARRS. For personal use only; all rights reserved
wire and sheath
in place.
Then,
advance
a stiff, 0.035-in.
(0.089
cm)
guidewire
through the sheath. Remove the sheath, leaving the Cope
guidewire
as the safety
wire and the 0.035-in.
(0.089
catheter
assembly
over
the Cope
wire
into the site
as
noted earlier. Withdraw the wire until approximately 1-2 cm of the distal tip protrudes from the catheter tip. Estimate the desired curvature of the catheter tip fluoroscopically. Then, shape the distal portion
ofthe
0.020-in.
malleable
steering
curve
(Fig. 2). Insert the curved
Cope
guidewire
and
under fluoroscopic the
catheter
advance
control.
and
wire by hand to the required
steering
it completely
The steering
will not
extend
from
wire
coaxially
beside
the
to the handle of the wire wire is 2-3 mm shorter than
the
tip.
If sufficient
space
is
available, the distal portion of the catheter and flexible Cope wire will assume the shape of the curved steering wire. The handle of the steering wire can be used to change the position of the distal catheter tip to select the desired direction. In order to aid in manipulation of the Cope wire, a steering handle (C. R. Bard, Billenica, MA) can be used to rotate the curved wire tip. The combination of curved catheter
and Cope wire can then be used to probe the site, which aids in cannulation and guidewire placement. The possibility of spring-coil tip detachment from the mandril ofCope-type wires during withdrawal
through catheters has been suggested [5]. Therefore, wire resistance should be monitored carefully during removal. No instances of wire detachment occurred in this series.
Representative
Case
A 25-year-old
man
Report
was
admitted
with
flank. Six years earlier, he had sustained
fever
and
pain
stab wounds
in the
of the
ureter.
A working
diagnosis
of
right
to the abdomen
and chest without evidence of urologic injury. An excretory and contrast-enhanced CT scan showed right hydronephrosis filling
proximal
right
urogram without ureteral
obstruction with right pyelonephritis was made. Percutaneous nephrostomy and ureteral stent placement were requested. Antegrade pyelography via a 21 -gauge needle puncture showed marked hydronephrosis with high-grade stricture at the ureteropelvicjunction (UPJ). Initial attempts to cross the stricture failed. The curved steering technique described was then used successfully to advance safety
and working
guidewires
stent and nephrostomy quickly
improved
across
catheter
the stricture
were
then
placed,
(Fig. and
wire both
3). A ureteral the
patient
clinically.
percutaneous
age procedures,
399
empyema drainages. The malleable steering wine has been successfully used to shape the introducer catheter tip, enabling selective placement of the wire in all six procedures in which the technique was attempted. No complications occurred.
Discussion
The access set provides a rapid means of establishing a percutaneous track into the desired space and placing a working guidewire as well as a safety wire by using a smallgauge needle and single-puncture technique. Entry into the original site is thus preserved in the event that access is lost during catheter and guidewire manipulations. A similarly priced set, the Accu-Stik introducer system (Medi-tech, Watertown, MA), also permits single-puncture placement of a safety and working guidewire by using a coaxial system. However, it and other similar systems [3, 4] are not designed to permit selective manipulation of the primary guidewine on introducer catheter/dilator as is the access set used in this series. In situations in which selective placement of the pnimany guidewire would gain greater purchase or is necessary to continue the procedure, the use of the access set’s malleable steering wine provides a means to add a distal curve to the introducer catheter, which permits probing and selective cannulation. The maximum curvature used in this series was approximately 1 00 degrees. J-type curvatures of up to 1 80#{176} with a minimum diameter of 4 cm have been achieved experimentally. Small tight J curves are not possible because of the length and rigidity of the catheter and sheath hubs. Passage through the hubs may partially straighten and broaden the curvature placed in the wire. This effect tends to increase when the curve is greater than 90#{176} and when a narrow curvature is used. The changes in the curvature may be partially compensated for by increasing the tip angle 1020#{176} and shaping a narrower curve than estimated at fluonoscopy before initial insertion. The resulting curve after passage through the hubs will be maintained by the wire and catheter, if sufficient space is available at the target site. At our hospital, this set has been used successfully to gain excellent guidewire position in a wide variety of percutaneous interventionab procedures, greatly facilitating their completion.
REFERENCES
1 . Cope C. Conversion percutaneous
drainage
from small (0.018 procedures.
AiR
“)
to large (0.038 1982:138:170-171
2. Swartz W. New coaxial introducer system for percutaneous
“)
guidewires
on
drainage. AJR
1985:144:1277
3. Dawson 5, Papanicolaou N, Mueller PR, Ferrucci JT Jr. Preserving access during percutaneous catheterization using a double-guide-wire technique.
Results
The access
SET
cm) guidewire
as the working wire. Therapeutic maneuvers can then be performed. If a drainage catheter is to be left in position when the procedure is completed, overdilate the track 2- to 3-French to facilitate placement of the drain and removal of the safety wire. In instances in which the Cope wire cannot be directed into the optimal location, the malleable steering wire and introducer catheter can be used to direct the guidewire and catheter into the desired location. After the 21 -gauge needle has been removed, advance the introducer
ACCESS
AiR
set has been used successfully uroradiobogic
procedures,
four abdominal
abscess
in 38 cases; 25 seven biliany draindrainages, and two
1983:141:407
4. Jeffrey RB Jr. Modified
Cope introducer set for rapid insertion wire. AJR 1986:147:828-829 5. Quinn SF, Morse S. Complications from 0.01 8-in. floppy guidewires.
AJR
1990:154:1103-1104
of a safety platinum-tip
397
Technical
Note
I A New Percutaneous Procedures Garey
Access
Set for Interventional
L. McLelIan1
Image-guided percutaneous interventional procedures have been enhanced by the development of introducer systems and techniques that permit safe, small-needle, single-puncture access into the renal collecting system, biliany tree, or abscess cavity [1 , 2]. The development of double-guidewine techniques and equipment for the placement of a safety and working guidewine has further facilitated the procedures, ensuning site access, especially in complex or difficult cases [3, 4]. Although these developments have aided in the performance of percutaneous procedures, they do not provide a means of directly manipulating the introducer catheter selectively into a ureter, bile duct, on abscess track. Often a series of catheter and guidewine manipulations are necessary to achieve the desired guidewine and catheter placement. The ability to place the introducer catheter and primary guidewine selectively may eliminate the need for these maneuvens. This paper describes a percutaneous access set that provides for the introduction of both working and safety guidewires and permits the introducer catheter to attain vanious degrees of distal curvature for selective placement of the primary guidewire and catheter.
Materials
The percutaneous in this report
a matching
cm-long
dilator
access
set (Cook
Inc.
,
Bloomington,
IN)
June 1 8, 1990:
Department
of Radiology,
accepted University
after revision of Florida
August Health
February
1991 0361-803X/91/1
with a 0.018-in.
stiffening
catheter
with
a 4.5-French
to the 4.5-French with
a 0.0i8-in.
cannula;
catheter;
end
end hole
a 7.5-French,
20-
end hole back
loaded
and a 4.5-French,
20-cm
(Fig. i).
hole
The procedure for using the access set is as follows: After the entry site is selected and prepared, make the initial puncture under fluoroscopic needle
control
is in the
with
desired
the location
21 -gauge and
trocar
the
needle.
When
is opacified,
site
pass
the
the
----
LZJ======
i4
D
=
-:3r:
-
-
-
-_
de-
Fig. 1.-Access set contains the following components: 7.5-French sheath (A), backloaded over 4.5-French introducer catheter (B), 19-gauge stiffening cannula (C), 0.020-in. malleable steering wire (D), 0.018-in. Cope mandril guidewire (E), 4.5-French fascial dilator (F), and 21-gauge trocar needle (G).
6, 1990. Science
Center/Jacksonville,
655 W. Eighth
L. McLellan. AJR 156:397-399,
catheter
steel
straight
and luer-locked fascial
40-cm-long
1 9-gauge
------
consists of a 21 -gauge, 1 5-cm trocar puncture needle; a 0.018-in. (0.046 cm), 80-cm-long, curved-tip Cope-mandril guidewire with platinum alloy spring guide; a 0.020-in. (0.051 cm), 42.5-cm-long malleable mandril steering wire with a 5-cm, right-angle
1
with
and Methods
scribed
Received
handle; a 4.5-French,
562-0397
© American
Roentgen
Ray Society
St.
,
Jacksonville,
FL 32209.
Address
reprint
requests
to G.
McLELLAN
Downloaded from www.ajronline.org by 117.253.220.249 on 10/21/15 from IP address 117.253.220.249. Copyright ARRS. For personal use only; all rights reserved
398
AJA:156,
February
1991
Fig. 2.-Demonstration of malleable steering wire with components labeled as in Fig. 1. A, Curved end of Cope wire (E) is seen cxtending from tip of 4.5-French introducer catheter (B). End of steering wire (D) has been handshaped to desired curvature. B, With Cope wire (E) and catheter (B) held in position, steering wire is placed coaxially into catheter and advanced completely to bend in wire. End of catheter and Cope wire have assumed shape of steering wire.
B
A
Fig. 3.-A, Spot radiograph shows a 21-gauge needle tip (small arrow) and proximal portion of a Cope wire (large arrow) within dilated renal pelvis. Note ureteropelvic junction (UPJ) strictures (arrowheads). B, Spot radiograph shows curve (arrowheads) introduced into catheter by placing hand-shaped steering wire into it. Cope wire (arrow) has been manipulated across LJPJ stricture. C, A spot radiograph shows curved steering wire (arrowheads) without platinum portion of cope wire (arrow) superimposed over it. D, A 0.035-in. working guidewire (arrow) has been introduced through sheath (arrowheads) adjacent to Cope wire.
0.018-in.
cases,
Cope
direct
guidewire
the guidewire
through
distally
the
needle.
to ensure
In biliary
adequate
and
renal
purchase
withdraw
the needle,
in the introducer
leaving
catheter
Place the steel cannula
within
Advance
step-off
within the site, and unlock the outer sheath from the inner catheter.
the mid-ureter or distal common duct. As there is an abrupt at the weld of the tapered mandril and spring coil portion of the guidewire, do not withdraw this area of the wire through either the needle or metal cannula because the wire could shear [5]. Then
this assembly
the wire in place.
and outer sheath and lock it in position.
Hold
the wire,
sheath
to the
over the guidewire
cannula, desired
and catheter
location.
When
into the desired
stationary, other
than
position
and advance minimal
curvature
the of
AJR:i56,
NEW
February 1991
the wire is encountered,
unlock
the steel cannula
PERCUTANEOUS
from the assembly,
hold the cannula and wire in position, and advance the catheter and sheath into position. Observing this caveat will avoid kinking of the wire. Remove the inner catheter and cannula and leave the Cope
Downloaded from www.ajronline.org by 117.253.220.249 on 10/21/15 from IP address 117.253.220.249. Copyright ARRS. For personal use only; all rights reserved
wire and sheath
in place.
Then,
advance
a stiff, 0.035-in.
(0.089
cm)
guidewire
through the sheath. Remove the sheath, leaving the Cope
guidewire
as the safety
wire and the 0.035-in.
(0.089
catheter
assembly
over
the Cope
wire
into the site
as
noted earlier. Withdraw the wire until approximately 1-2 cm of the distal tip protrudes from the catheter tip. Estimate the desired curvature of the catheter tip fluoroscopically. Then, shape the distal portion
ofthe
0.020-in.
malleable
steering
curve
(Fig. 2). Insert the curved
Cope
guidewire
and
under fluoroscopic the
catheter
advance
control.
and
wire by hand to the required
steering
it completely
The steering
will not
extend
from
wire
coaxially
beside
the
to the handle of the wire wire is 2-3 mm shorter than
the
tip.
If sufficient
space
is
available, the distal portion of the catheter and flexible Cope wire will assume the shape of the curved steering wire. The handle of the steering wire can be used to change the position of the distal catheter tip to select the desired direction. In order to aid in manipulation of the Cope wire, a steering handle (C. R. Bard, Billenica, MA) can be used to rotate the curved wire tip. The combination of curved catheter
and Cope wire can then be used to probe the site, which aids in cannulation and guidewire placement. The possibility of spring-coil tip detachment from the mandril ofCope-type wires during withdrawal
through catheters has been suggested [5]. Therefore, wire resistance should be monitored carefully during removal. No instances of wire detachment occurred in this series.
Representative
Case
A 25-year-old
man
Report
was
admitted
with
flank. Six years earlier, he had sustained
fever
and
pain
stab wounds
in the
of the
ureter.
A working
diagnosis
of
right
to the abdomen
and chest without evidence of urologic injury. An excretory and contrast-enhanced CT scan showed right hydronephrosis filling
proximal
right
urogram without ureteral
obstruction with right pyelonephritis was made. Percutaneous nephrostomy and ureteral stent placement were requested. Antegrade pyelography via a 21 -gauge needle puncture showed marked hydronephrosis with high-grade stricture at the ureteropelvicjunction (UPJ). Initial attempts to cross the stricture failed. The curved steering technique described was then used successfully to advance safety
and working
guidewires
stent and nephrostomy quickly
improved
across
catheter
the stricture
were
then
placed,
(Fig. and
wire both
3). A ureteral the
patient
clinically.
percutaneous
age procedures,
399
empyema drainages. The malleable steering wine has been successfully used to shape the introducer catheter tip, enabling selective placement of the wire in all six procedures in which the technique was attempted. No complications occurred.
Discussion
The access set provides a rapid means of establishing a percutaneous track into the desired space and placing a working guidewire as well as a safety wire by using a smallgauge needle and single-puncture technique. Entry into the original site is thus preserved in the event that access is lost during catheter and guidewire manipulations. A similarly priced set, the Accu-Stik introducer system (Medi-tech, Watertown, MA), also permits single-puncture placement of a safety and working guidewire by using a coaxial system. However, it and other similar systems [3, 4] are not designed to permit selective manipulation of the primary guidewine on introducer catheter/dilator as is the access set used in this series. In situations in which selective placement of the pnimany guidewire would gain greater purchase or is necessary to continue the procedure, the use of the access set’s malleable steering wine provides a means to add a distal curve to the introducer catheter, which permits probing and selective cannulation. The maximum curvature used in this series was approximately 1 00 degrees. J-type curvatures of up to 1 80#{176} with a minimum diameter of 4 cm have been achieved experimentally. Small tight J curves are not possible because of the length and rigidity of the catheter and sheath hubs. Passage through the hubs may partially straighten and broaden the curvature placed in the wire. This effect tends to increase when the curve is greater than 90#{176} and when a narrow curvature is used. The changes in the curvature may be partially compensated for by increasing the tip angle 1020#{176} and shaping a narrower curve than estimated at fluonoscopy before initial insertion. The resulting curve after passage through the hubs will be maintained by the wire and catheter, if sufficient space is available at the target site. At our hospital, this set has been used successfully to gain excellent guidewire position in a wide variety of percutaneous interventionab procedures, greatly facilitating their completion.
REFERENCES
1 . Cope C. Conversion percutaneous
drainage
from small (0.018 procedures.
AiR
“)
to large (0.038 1982:138:170-171
2. Swartz W. New coaxial introducer system for percutaneous
“)
guidewires
on
drainage. AJR
1985:144:1277
3. Dawson 5, Papanicolaou N, Mueller PR, Ferrucci JT Jr. Preserving access during percutaneous catheterization using a double-guide-wire technique.
Results
The access
SET
cm) guidewire
as the working wire. Therapeutic maneuvers can then be performed. If a drainage catheter is to be left in position when the procedure is completed, overdilate the track 2- to 3-French to facilitate placement of the drain and removal of the safety wire. In instances in which the Cope wire cannot be directed into the optimal location, the malleable steering wire and introducer catheter can be used to direct the guidewire and catheter into the desired location. After the 21 -gauge needle has been removed, advance the introducer
ACCESS
AiR
set has been used successfully uroradiobogic
procedures,
four abdominal
abscess
in 38 cases; 25 seven biliany draindrainages, and two
1983:141:407
4. Jeffrey RB Jr. Modified
Cope introducer set for rapid insertion wire. AJR 1986:147:828-829 5. Quinn SF, Morse S. Complications from 0.01 8-in. floppy guidewires.
AJR
1990:154:1103-1104
of a safety platinum-tip
