754
TECHNICAL NOTES
the site of the obstruction and the duodenum.Excessive proximal sideholes are to be avoided since hemobilia may result when sideholes are positioned in the intraparenchymal segment of the catheter. Introduction of the catheter is facilitated when it is passed over a very rigid guidewire. A special guidewire for manipulations through the liver has been designed by Lunderquist3 . Constructed of solid steel with a flexible tip welded to its distal portion, its firmness exerts sufficient force upon the catheter to overcome resistance in the liver. Once the catheter has been introduced, function is checked by injecting and withdrawing contrast material. A free flow of contrast material in and out of the ductal system as well as into the duodenum confirms proper function. DISCUSSION Successful longterm transhepatic biliary drainage depends on positioning numerous sldeholes both above and below an obstruction and maintaining continued patency of the lumen and the sideholes. Since bile tends to form sludge deposits, any artificial endoprosthesis will eventually become obstructed. Patency is prolonged, however, by the use of larger diameter catheters and larger sldeholes. For this purpose we originally employed catheters as large as 12-14F but found that a smaller catheter (8.3 F) could be introduced more easily and would remain functional for at least three months in most cases. In addition, the smaller size permits the introduction of multiple catheters in patients with multiple intrahepatic obstructions (Fig. 1). This smaller catheter can also be readily shaped into a pigtail tip configuration which anchors in the duodenum and helps
September 1979
prevent retrograde migration. In several of our early patients, migration of straight catheters proved to be a recurrent clinical problem, and in one case the catheter actually withdrew completely from the liver. The catheter is positioned so that the 3 em segment distal to the right angle bend is located in the duodenum. This provides a surface where multiple outflow sidehotes permit egress of bile into the gastrointestinal tract (Fig. 2). The intraduodenal segment is particularly important for maintaining antegrade biliary drainage in patients with lesions obstructing the periampullary portion of the distal common bile duct. Once the catheter has been positioned, it is placed to external drainage for 24 hours and then capped externally. The patient is instructed to irrigate the catheter with sterile saline every other day and the catheter is routinely replaced over a guidewire on an outpatient basis every three months. REFERENCES 1. Molnar W, Stockum AE: Relief of obstructive jaundice through percutaneous transhepatic catheter-a new therapeutic method. Am J RoentgenOI122:356-367, Oct 1974 2. Tylen U, Hoevels J, Vang J: Percutaneous transhepatic cholangiography with external drainage of obstructive biliary lesions. Surg GynecolObstet 144:13-18, Jan 1977 3. Ring EJ, OleagaJA, FreimanDB, et al: Therapeuticapplications of catheter cholangiography. Radiology 128:333-338, Aug 1978 1 From the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa. 19104. Received Nov. 30, 1978; accepted and revision requested Jan. 17, 1979; revision received Feb.
7. 2 3
Cook, Inc., Bloomington, Ind. Surgimed, Summerville, S.C.
as
Use of the 1 mm "J"-Guidewire for Selective Catheterization 1 Barry A. Sacks, M.D., and Joseph C. Sequeira, M.D.2 The use of 1 mm "J"-guidewires in place of presently available larger guidewires for selective catheterization in atherosclerotic patients is described. INDEX TERM:
Catheters and catheterization, technique
Radiology 132:754-755, September 1979
The use of a 3 mm "J"-guidewire, with or without a movable core. is virtually standard in patients with atherosclerotic and tortuous vessels. The broadly rounded blunt leading end allows negotiation around awkward curves and atheromatous plaques in the most atraumatic fashion. We wish to describe the use of a 1 mm "J", .889 em (0.35 in.) guidewire 2 for catheterization of secondary branches of major vessels as an extension of the principle commonly used when an attempt is made to advance catheters further into a particular vessel (Fig. 1). We have used this technique in approximately 26 patients, with 23 successes
Fig. 1. a. The 1 mm "J"-guidewire is seen advanced far distally following selective catheterization. Curves are easily negotiated and the catheter is not "backed out" by the gUidewire being held up on small side branches. b. Catheter shown advanced over the wire to a more selective position.
TECHNICAL NOTES
Vo\. 132
and 3 failures. The failures were due to the following reasons: (a) inability to advance the guidewire subselectively far distally (1 case); (b) continual buckling out of the guidewire when an
attempt was made to pass the catheter over it (1 case); and ( c) stenosis at the origin of the celiac axis. In our opinion, the 1 mm "J"-guidewire offers significant advantages over presently available guidewires. It is small enough in diameter to form easily in the vessel and be advanced far distally, without "backing out" and displacing the catheter; it allows easy negotiation of multiple tortuous curves such as in the splenic artery without the danger of dissection (Fig. 1); and it tends not to be held up on smaller side branches. We have found .889 em to be the optimal size because, despite its smallness, it offers just enough stability to support catheter
Single Mini-Catheter Technique for Abdominal Aortography and Selective Injection 1 I. F. Hawkins, Jr., M.D., Michael K. Haseman, M.D., and Phillip N. Gelfand, M.D. A single mini-catheter technique for abdominal aortography and selective injection using 4.1 and 5 French polyethylene catheters In the Shepherd's Crook configuration is described. Studies made In 365 patients were of high quality and without complications. This technique is easily learned, less time consuming, and safer than previous pig-tailed mini-catheter and larger catheter techniques. INDEX TERMS: Angiography. technique. Cathetersand catheterization,technique • (Abdominal aorta,aortography, 9 (81].121) • (Abdominal aorta,catheter, aortography, 9[81].1211)
Radiology 132:755-757, September 1979
Over the past seven years, we have used 4.1 and 5 French catheters for all visceral and extremity angiography (1-5), because of their greater safety and maneuverability as compared to larger catheters. (The 4.1-F catheters have been previously used primarily in young women, renal transplant, extremity, and high-risk atherosclerotic patients, but for the last eight months, we have employed them in more than 95 % of all patients, except those requiring arch aortography.) Mani et al. (6, 7) recently tested flow rates for similar catheters. For the last year and a half, we have used a single 4.1 (55 cm) or 5 (60 cm) French Shepherd's Crook catheter'' with four distal side holes for both aortography and selective injection, which obviates catheter exchange and further reduces complications. TECHNIQUE The catheter has a primary large curve and a distal reverse curve (Fig. 1, c). The latter curve, in the unformed configuration (Fig. 1, a), prevents entry into the lumbar arteries or other aortic branches during abdominal aortography. Using the 5-F catheter, 15 ml Renografin 76 (Squibb) was injected for 3 seconds; using the 4.1-F catheter, 12 ml for 4 seconds. The catheter was positioned approximately 1 vertebral body below the area being studied. A sustained Val salva was used during injection, particularly in larger patients and those in whom the 4.1-F catheter was used. The 5-F catheter was
755
Technical Notes
advancement. We have used this technique with a great deal of success in selective catheterization of secondary branches of major visceral arteries, and also as a lead wire in transluminal angioplasty procedures. In severely atherosclerotic iliac vessels when the 3 mm "J"-guidewire does not pass through easily, this wire can be advanced into the aorta.
1 From the Department of Radiology, Beth Israel Hospital, Harvard Medical School, 330 Brookline Ave., Boston, Mass. 12205. Received Nov. 2, 1978; accepted and revision requested Dec. 29; revision received Jan. 23, 1979. 2 Present address: University Hospital, 75 E. Newton St., Boston, Mass. 02118. 3 Cook, lnc., Bloomington, Ind. as
formed into the Shepherd's Crook configuration, either in the aortic arch in shorter patients or with the aid of a mini-curved deflector wire with a 5-mm radius (0.71 mm for the 4.1 and 0.89 mm for the 5-F catheters, respectively) (Fig. 1). After the Shepherd's Crook was formed, selective catheterization of any branch of the aorta (lumbar, bronchial, middle adrenal, renal, celiac, superior and inferior mesenteric) could be performed without difficulty. The 5-F catheter is comprised of medium density polyethylene, giving it excellent torque and a high flow rate for its size. The Shepherd's Crook is particularly stable for selective injection (12 ml Renografin 76/sec for the 5-F catheter, 10 ml/sec for the 4.1-F catheter); much more so than the 5 French Cobra configuration, which will frequently recoil from the orifice at flow rates of 10 mllsec. The catheters are manufactured in three curve sizes: A for small aortas, B for average, C for large. Tailoring catheter size to the diameter of the aorta is particularly important in both aortography and selective injection; in the former, a small-radius catheter in a large aorta may spontaneously form a Shepherd's Crook, resulting in inadvertent selective injection, while in the latter, a Shepherd's Crook with a small radius may recoil from the selected artery during injection. If the Shepherd's Crook major radius is too large, the primary curve will be compressed by the aorta and the tip of the catheter may not reach to the lateral aortic wall. However, the tip may be extended by advancing the stiff end of the 0.35-inch (.889-cm) guide to the superlormost portion of the major curve. This will tend to change the radius of the major curve so that the tip of the catheter extends to the aortic wall. Frequently the Shepherd's Crook will "seek out" the left gastric artery by initially catheterizing the celiac artery, then slowly retracting during test injection. The inferior adrenal artery can be catheterized by a similar method. We have performed aortography with the Shepherd's Crook catheter in 365 patients (using a 4.1-F catheter in 120 patients) without inadvertent injection of lumbar arteries during aortography or catheter recoil during selective injection. With the advent of superselective catheterization, magnification, and pharmacoangiography, abdominal aortography has become less important. With the exception of primary diseases involving the aorta and its proximal branches, the aortogram presently serves primarily as a "roadmap" for subsequent catheter placement. Even though the injection rate for the 4.1-F catheter is considerably lower than that of the previously used
TECHNICAL NOTES
the site of the obstruction and the duodenum.Excessive proximal sideholes are to be avoided since hemobilia may result when sideholes are positioned in the intraparenchymal segment of the catheter. Introduction of the catheter is facilitated when it is passed over a very rigid guidewire. A special guidewire for manipulations through the liver has been designed by Lunderquist3 . Constructed of solid steel with a flexible tip welded to its distal portion, its firmness exerts sufficient force upon the catheter to overcome resistance in the liver. Once the catheter has been introduced, function is checked by injecting and withdrawing contrast material. A free flow of contrast material in and out of the ductal system as well as into the duodenum confirms proper function. DISCUSSION Successful longterm transhepatic biliary drainage depends on positioning numerous sldeholes both above and below an obstruction and maintaining continued patency of the lumen and the sideholes. Since bile tends to form sludge deposits, any artificial endoprosthesis will eventually become obstructed. Patency is prolonged, however, by the use of larger diameter catheters and larger sldeholes. For this purpose we originally employed catheters as large as 12-14F but found that a smaller catheter (8.3 F) could be introduced more easily and would remain functional for at least three months in most cases. In addition, the smaller size permits the introduction of multiple catheters in patients with multiple intrahepatic obstructions (Fig. 1). This smaller catheter can also be readily shaped into a pigtail tip configuration which anchors in the duodenum and helps
September 1979
prevent retrograde migration. In several of our early patients, migration of straight catheters proved to be a recurrent clinical problem, and in one case the catheter actually withdrew completely from the liver. The catheter is positioned so that the 3 em segment distal to the right angle bend is located in the duodenum. This provides a surface where multiple outflow sidehotes permit egress of bile into the gastrointestinal tract (Fig. 2). The intraduodenal segment is particularly important for maintaining antegrade biliary drainage in patients with lesions obstructing the periampullary portion of the distal common bile duct. Once the catheter has been positioned, it is placed to external drainage for 24 hours and then capped externally. The patient is instructed to irrigate the catheter with sterile saline every other day and the catheter is routinely replaced over a guidewire on an outpatient basis every three months. REFERENCES 1. Molnar W, Stockum AE: Relief of obstructive jaundice through percutaneous transhepatic catheter-a new therapeutic method. Am J RoentgenOI122:356-367, Oct 1974 2. Tylen U, Hoevels J, Vang J: Percutaneous transhepatic cholangiography with external drainage of obstructive biliary lesions. Surg GynecolObstet 144:13-18, Jan 1977 3. Ring EJ, OleagaJA, FreimanDB, et al: Therapeuticapplications of catheter cholangiography. Radiology 128:333-338, Aug 1978 1 From the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa. 19104. Received Nov. 30, 1978; accepted and revision requested Jan. 17, 1979; revision received Feb.
7. 2 3
Cook, Inc., Bloomington, Ind. Surgimed, Summerville, S.C.
as
Use of the 1 mm "J"-Guidewire for Selective Catheterization 1 Barry A. Sacks, M.D., and Joseph C. Sequeira, M.D.2 The use of 1 mm "J"-guidewires in place of presently available larger guidewires for selective catheterization in atherosclerotic patients is described. INDEX TERM:
Catheters and catheterization, technique
Radiology 132:754-755, September 1979
The use of a 3 mm "J"-guidewire, with or without a movable core. is virtually standard in patients with atherosclerotic and tortuous vessels. The broadly rounded blunt leading end allows negotiation around awkward curves and atheromatous plaques in the most atraumatic fashion. We wish to describe the use of a 1 mm "J", .889 em (0.35 in.) guidewire 2 for catheterization of secondary branches of major vessels as an extension of the principle commonly used when an attempt is made to advance catheters further into a particular vessel (Fig. 1). We have used this technique in approximately 26 patients, with 23 successes
Fig. 1. a. The 1 mm "J"-guidewire is seen advanced far distally following selective catheterization. Curves are easily negotiated and the catheter is not "backed out" by the gUidewire being held up on small side branches. b. Catheter shown advanced over the wire to a more selective position.
TECHNICAL NOTES
Vo\. 132
and 3 failures. The failures were due to the following reasons: (a) inability to advance the guidewire subselectively far distally (1 case); (b) continual buckling out of the guidewire when an
attempt was made to pass the catheter over it (1 case); and ( c) stenosis at the origin of the celiac axis. In our opinion, the 1 mm "J"-guidewire offers significant advantages over presently available guidewires. It is small enough in diameter to form easily in the vessel and be advanced far distally, without "backing out" and displacing the catheter; it allows easy negotiation of multiple tortuous curves such as in the splenic artery without the danger of dissection (Fig. 1); and it tends not to be held up on smaller side branches. We have found .889 em to be the optimal size because, despite its smallness, it offers just enough stability to support catheter
Single Mini-Catheter Technique for Abdominal Aortography and Selective Injection 1 I. F. Hawkins, Jr., M.D., Michael K. Haseman, M.D., and Phillip N. Gelfand, M.D. A single mini-catheter technique for abdominal aortography and selective injection using 4.1 and 5 French polyethylene catheters In the Shepherd's Crook configuration is described. Studies made In 365 patients were of high quality and without complications. This technique is easily learned, less time consuming, and safer than previous pig-tailed mini-catheter and larger catheter techniques. INDEX TERMS: Angiography. technique. Cathetersand catheterization,technique • (Abdominal aorta,aortography, 9 (81].121) • (Abdominal aorta,catheter, aortography, 9[81].1211)
Radiology 132:755-757, September 1979
Over the past seven years, we have used 4.1 and 5 French catheters for all visceral and extremity angiography (1-5), because of their greater safety and maneuverability as compared to larger catheters. (The 4.1-F catheters have been previously used primarily in young women, renal transplant, extremity, and high-risk atherosclerotic patients, but for the last eight months, we have employed them in more than 95 % of all patients, except those requiring arch aortography.) Mani et al. (6, 7) recently tested flow rates for similar catheters. For the last year and a half, we have used a single 4.1 (55 cm) or 5 (60 cm) French Shepherd's Crook catheter'' with four distal side holes for both aortography and selective injection, which obviates catheter exchange and further reduces complications. TECHNIQUE The catheter has a primary large curve and a distal reverse curve (Fig. 1, c). The latter curve, in the unformed configuration (Fig. 1, a), prevents entry into the lumbar arteries or other aortic branches during abdominal aortography. Using the 5-F catheter, 15 ml Renografin 76 (Squibb) was injected for 3 seconds; using the 4.1-F catheter, 12 ml for 4 seconds. The catheter was positioned approximately 1 vertebral body below the area being studied. A sustained Val salva was used during injection, particularly in larger patients and those in whom the 4.1-F catheter was used. The 5-F catheter was
755
Technical Notes
advancement. We have used this technique with a great deal of success in selective catheterization of secondary branches of major visceral arteries, and also as a lead wire in transluminal angioplasty procedures. In severely atherosclerotic iliac vessels when the 3 mm "J"-guidewire does not pass through easily, this wire can be advanced into the aorta.
1 From the Department of Radiology, Beth Israel Hospital, Harvard Medical School, 330 Brookline Ave., Boston, Mass. 12205. Received Nov. 2, 1978; accepted and revision requested Dec. 29; revision received Jan. 23, 1979. 2 Present address: University Hospital, 75 E. Newton St., Boston, Mass. 02118. 3 Cook, lnc., Bloomington, Ind. as
formed into the Shepherd's Crook configuration, either in the aortic arch in shorter patients or with the aid of a mini-curved deflector wire with a 5-mm radius (0.71 mm for the 4.1 and 0.89 mm for the 5-F catheters, respectively) (Fig. 1). After the Shepherd's Crook was formed, selective catheterization of any branch of the aorta (lumbar, bronchial, middle adrenal, renal, celiac, superior and inferior mesenteric) could be performed without difficulty. The 5-F catheter is comprised of medium density polyethylene, giving it excellent torque and a high flow rate for its size. The Shepherd's Crook is particularly stable for selective injection (12 ml Renografin 76/sec for the 5-F catheter, 10 ml/sec for the 4.1-F catheter); much more so than the 5 French Cobra configuration, which will frequently recoil from the orifice at flow rates of 10 mllsec. The catheters are manufactured in three curve sizes: A for small aortas, B for average, C for large. Tailoring catheter size to the diameter of the aorta is particularly important in both aortography and selective injection; in the former, a small-radius catheter in a large aorta may spontaneously form a Shepherd's Crook, resulting in inadvertent selective injection, while in the latter, a Shepherd's Crook with a small radius may recoil from the selected artery during injection. If the Shepherd's Crook major radius is too large, the primary curve will be compressed by the aorta and the tip of the catheter may not reach to the lateral aortic wall. However, the tip may be extended by advancing the stiff end of the 0.35-inch (.889-cm) guide to the superlormost portion of the major curve. This will tend to change the radius of the major curve so that the tip of the catheter extends to the aortic wall. Frequently the Shepherd's Crook will "seek out" the left gastric artery by initially catheterizing the celiac artery, then slowly retracting during test injection. The inferior adrenal artery can be catheterized by a similar method. We have performed aortography with the Shepherd's Crook catheter in 365 patients (using a 4.1-F catheter in 120 patients) without inadvertent injection of lumbar arteries during aortography or catheter recoil during selective injection. With the advent of superselective catheterization, magnification, and pharmacoangiography, abdominal aortography has become less important. With the exception of primary diseases involving the aorta and its proximal branches, the aortogram presently serves primarily as a "roadmap" for subsequent catheter placement. Even though the injection rate for the 4.1-F catheter is considerably lower than that of the previously used
