Puncture Angle Research Articles

Puncture angle choice of ultrasound guided automatic kidney biopsy in 518 cases

Objective To elevate the achievement rate of kidney biopsy puncture through the analysis of puncture angle choice of ultrasound guided automatic kidney biopsy in 518 patients. Methods Under the guidance of color Doppler ultrasound,using the 3.5MHz probe with probe holder,we performed kidney biopsy in the degrees of 40°(group X),45°(group Y),60°(group Z) and 70°(group P) with the horizontal plane. Resnlts The total achievement ratio is 100 %. The one time success rate in group Y and group Z is 100 % (group Y, 164/164 ; group Z, 186/186) ;group X is 4.8% (22/46) ;group P is 84.4% (103/122).Conclusion The automatic kidney biopsy an- gle under the guidance of ultrasound should be between 45° and 60° with the horizontal plane which is safe and has higher achievement ratio. In the meantime, complications can be avoided. Key words: Ultrasonography; Kidney; Biopsy; Angle

Amniocentesis under permanent ultrasonic control--advantages of a special procedure

Advocates of the so-called "free hand technique" in amniocentesis argue against permanent sonographic control as follows: "Free hand technique" is the only method enabling vertical guiding of the puncture needle between abdominal wall and amniotic cavity, and hence to cover the shortest distance with the lowest risk of traumatisation. "Free hand technique" is the only method permitting sensitive guiding of the needle in amniocentesis, since the puncturing doctor can use both hands without requiring one hand for sonographic examination. Amniocentesis under permanent sonographic control is claimed to raise serious problems in guaranteeing the necessary sterility. The authors present a modification of the puncture method with permanent sonographic control. This does away with all of the above arguments against permanent sonographic control, whereas all of its obvious advantages are retained (greater safety, less risk of injury). The method employs a fixation scaffolding and an aiming groove for routine sector scanning (Figures 1 and 2). The entire system is covered in a sterile manner by a pasted-on foil sheeting after having introduced the sonographic contact gel. The only contact medium for the skin is a disinfecting agent enabling satisfactory imaging (Figure 4). This method offers the following advantages over the methods using conventional puncture soundheads: Better possibility of disinfection. No rigid guiding of needle, and hence correction can be effected even during puncture. Adjacent levels can be observed by free displacement of scanner and needle. Modifiable puncture angle in respect of skin and uterus. The fixation scaffolding does away with the need for an assistant, and enables tremor-free fixation of the scanner during puncture.(ABSTRACT TRUNCATED AT 250 WORDS)

1A1-C08 CMTD(曲がり多重チューブ)を用いた肝穿刺システムの開発と胆管への穿刺のための基礎的検討(手術支援ロボティクス・メカトロニクス)

The authors developed CMTD (Curved Multi-Tube Device) and studied the system which performed puncture to the liver by machine control.CMTD, which consists of a straight outer needle and a curved inner needle, can revise the error that occurred during puncture. By the system, we detect the puncture angle of the needle during puncture by clicking points of needle on the ultrasound image as a sensor with somascope. We supposed PTCD(percutaneous transhepatic cholangiodrainage) as an environment, and we tested puncture to the silicon tube which simulated a bile duct using this system and studied the effectiveness of this.

Does the Age Affect the Fluoroscopy‐Guided Transseptal Puncture in Catheter Ablation of Atrial Fibrillation?

The anatomical differences with age may raise difficulty in determining the proper positioning of the transseptal puncture site in the therapeutic left heart catheterization. This study investigated whether age affects the fluoroscopy-guided transseptal puncture in the catheter ablation of atrial fibrillation. Fifty patients (52 +/- 12 years, 35 men) who underwent ablation for paroxysmal/persistent atrial fibrillation were included. The patients were divided into two groups according to their age (cut-point 50 y/o): young group (n = 20) and old group (n = 30). In the 30 degrees right anterior oblique view (RAO), the width between the transseptal puncture site and coronary sinus ostium (H (N-CSO)) was longer in old-age group (14.4 +/- 9.4 vs 10.9 +/- 10.4 mm, P = 0.034). In the 60 degrees left anterior oblique view (LAO) view, the angle of the direction of the transseptal needle (N-angle) was less in the old-age group (56.0 +/- 10.0 degrees vs 58.4 +/- 9.8 degrees , P = 0.041). The ratio of the transseptal puncture site-coronary sinus ostium (CSO) distance over the distance between the superior vena cava-right atrial junction and CSO (V(N-CSO)/V(J-CSO)) was significantly higher in the old-age group (0.73 +/- 0.12 vs 0.63 +/- 0.2, P = 0.009). The transseptal puncture site in the RAO view moved higher and more posterior and the transseptal puncture angle in the LAO view decreased with age. These findings highlight the influence of age on the atrial anatomy and transseptal puncture site.

Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report

Background Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization. Case Description This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF. Conclusion Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.

New advances in technique for pediatric caudal and epidural placement

Epidural anesthesia can provide safe and effective analgesia in children; however, it is essential to give consideration to which epidural approach will be superior and which confirmation technique, if needed, will assist optimal catheter placement. Accurate segmental localization is important in pediatric epidurals, for avoiding local anesthetic toxicity and side effects through maximizing effect with minimal doses. Nerve stimulation and electrocardiography allow continuous and real-time monitoring of the position of the catheter tip. Electrical epidural stimulation may also help warn of intrathecal, subarachnoid or intravascular catheter or needle placement. Ultrasound guidance during central block procedures may be very advantageous in cases where clear visibility of anatomical structures and block-related equipment is possible. Ultrasound imaging can be of great help to determine the depth of the epidural space and estimate the best needle puncture site and angle. Methods to enhance the visibility of structures are introduced. Innovative techniques for use in pediatric neuraxial anesthesia will ultimately increase our confidence with the procedures and expand the utilization of regional anesthesia in children.

Standardization of needlestick injury and evaluation of a novel virus-inhibiting protective glove

Rubber surgical gloves worn as a barrier to prevent contamination from body fluids offer relative protection against contamination through direct percutaneous injuries involving needles, scalpel blades or bone fragments. To determine the main experimental parameters influencing the volume of blood transmitted by a hollow-bore needle (worst case scenario) during an accidental puncture, we designed an automatic puncture apparatus. Herpes simplex type 1 virus (HSV1), a model for enveloped viruses, was used as a 'marker' in an in-vitro gelatine model. Of the experimental parameters studied, the most critical influences were found to be needle diameter and puncture depth, whereas puncture speed, puncture angle and glove-stretching feature appeared to be less influential. A single glove reduced the volume of blood transferred by 52% compared with no glove, but double gloving offered no additional protection against hollow-bore needle punctures. Using 'standardized' puncture conditions, the virus-inhibiting surgical glove G-VIR elicited an 81% reduction in the amount of HSV1 transmitted as compared with single or double latex glove systems.

Image-guided puncture technique for the superior temporomandibular joint space: value of cone beam computed tomography (CBCT)

Temporomandibular joint (TMJ) disk perforation or adhesion requires arthrographic examination. However, puncture of the TMJ may result in damaging penetration of the middle cranial fossa. We investigated the effectiveness of penetrating the superior TMJ space using a safe image-guided puncture technique (IGPT). Fifty-two patients underwent cone beam computed tomography (CBCT) examination. Optimum angles and distances from the puncture site to the thinnest point of the glenoid fossa to penetrate the superior joint space were measured using three-directional images. Puncturing the superior articular cavity was immediately successful in 50 cases. Image measurements gave an average horizontal angle of 8.0 degrees (standard deviation [SD]: 9.2), an average coronal angle of 16 degrees (SD: 11.3), and an average distance of 27 mm (SD: 2.8). Variation in puncture angle among individuals indicated that CBCT examination is necessary preceding TMJ puncture. Preliminary clinical application has demonstrated the safety of IGPT using CBCT.

Unilateral transpedicular percutaneous vertebroplasty using puncture simulation

The aim of this study was to improve the accuracy of puncture to the median vertebral body using the unilateral transpedicular approach on percutaneous vertebroplasty (PVP). We have developed and evaluated a simple puncture simulation method based on the puncture angle determined by preoperative computed tomography (CT). Two groups were evaluated. The first (group A) comprised 23 patients (34 vertebral bodies) who had undergone PVP without preoperative puncture simulation before May 2004, and the second group (group B) comprised 24 patients (39 vertebral bodies) who had undergone preoperative puncture simulation and PVP after May 2004. CT in the prone position was performed, and the puncture angle on CT (PAC) via the vertebral arch pedicle targeting the anterior one-third median site of the vertebral body was determined. Puncture was performed by targeting the isocenter established on a fluoroscopic monitor based on the PAC. Determinations were made of the success rate (SR) of the median puncture of the vertebral body, the effect of treatment using the visual analogue score, and the overall procedural time between groups A and B. The SR was 56% (19/34 vertebral bodies) in group A, and 97% (37/38 vertebral bodies), including only one vertebral body in which it was difficult to perform the unilateral approach on CT images, in group B, with the difference being significant by Student's t-test (P < 0.001). Among patients with available follow-up data, the unipedicular and bipedicular approaches achieved adequate pain relief with mean decreases in pain severity of 5.1 +/- 2.6 and 5.9 +/- 2.8, respectively. No significant differences in the treatment effect between the two groups was observed (P = 0.811). The overall procedure time per puncture was shorten for the simulation group (36.0 min) than for group A (73.1 min), as shown by regression analysis. The preoperative PAC determination for PVP under fluoroscopy increased the completion rate of PVP by the unilateral transpedicular approach. This method should be accepted from the viewpoint of burden reduction on patients and surgeons.

Dural Tissue Trauma and Cerebrospinal Fluid Leak after Epidural Needle Puncture

The effects of epidural needle design, angle, and bevel orientation on cerebrospinal fluid leak after puncture have not been reported. The impact of these factors on leak rate was examined using a dural sac model. Dural trauma was examined using scanning electron microscopy. Human cadaveric dura, mounted on a cylindrical model, was punctured with epidural needles using a micromanipulator. Tissue was punctured at 15 cm H2O (left lateral decubitus) system pressure, and leak was measured at 25 cm H2O (semisitting) pressure. Leak rates and trauma were compared for the following: (1) six different epidural needles at 90 degrees, bevel parallel to the dural long axis; (2) 18-gauge Tuohy and 18-gauge Special Sprotte epidural needles, 30 degrees versus 90 degrees; (3) 18-gauge Tuohy, bevel perpendicular versus parallel to the dural long axis. With the 90 degrees puncture, bevel parallel, the greatest leak occurred with a 17-gauge Hustead (516 +/- 319 ml/15 min), and the smallest leak occurred with a 20-gauge Tuohy (100 +/- 112 ml/15 min; P = 0.0018). A 20-gauge Tuohy puncture led to statistically significant reductions in leak (P value range, 0.0001-0.0024) compared with all needles except the Special Sprotte. With the 30 degrees versus 90 degrees angle, 30 degrees punctures with an 18-gauge Tuohy produced nonstatistically significant leak reductions compared with the 18-gauge Tuohy at 90 degrees. The puncture angle made no difference for the Special Sprotte. Nonsignificant reductions were found for the Special Sprotte compared with the Tuohy. With the 18-gauge Tuohy bevel orientation, perpendicular orientation produced nonstatistically significant reductions in leak compared with parallel orientation. Cerebrospinal fluid leak after puncture was influenced most by epidural needle gauge. Leak rate was significantly less for the 20-gauge Tuohy needle.

Guidelines for the intramuscular positioning of EMG electrodes in the semispinalis capitis and cervicis muscles

The objective of the study was to establish guidelines for the application of fine-wire or needle electrodes in the semispinalis cervicis and semispinalis capitis muscles. First of all, measured data for the puncture angle and puncture depth of each muscle were determined in CT scans. Using a regression approach, a model relation of these data with the neck circumference was established. This made it possible to accurately determine the puncture angle and puncture depth on the basis of the known neck circumference. In a further step, the neck muscles of seven human cadavers were punctured with wires in order to check the workability of these guidelines. At the same time, the wires’ positions in relation to important structures (nerves, vessels) were studied. Both muscles can be punctured with a high degree of reliability. However, when puncturing the semispinalis cervicis muscle, one has to pass through a layer that contains vessels, nevertheless the risk of injury is regarded as very small. The technique enables intramuscular EMG measurements of the two muscles in manifold clinical problems.

Using a Dedicated Lung-Marker System for Localization of Pulmonary Nodules Before Thoracoscopic Surgery

Our aim was to evaluate the effectiveness of a commercially available dedicated lung-marker system for localization of pulmonary nodules before video-assisted thoracoscopic surgery. Guidewires were positioned under CT fluoroscopy guidance in 16 patients (11 men, five women; age range, 39-79 years; mean age, 60.4 years). We measured the size of the targeted nodule, its distance to the closest pleural surface, the angle between the introducer needle and the chest wall, and the time for performance of the procedure in each patient. Note was made of any complications after guidewire placement. In the 16 patients, the average nodule size was 6.7 mm (range, 3-12 mm), the average distance to the pleural surface was 10.6 mm (range, 3-22 mm), and the average pleural puncture angle was 59 degrees (range, 25-78 degrees). The marking procedure was completed within an average of 9.5 min (range, 7-15 min). Small pneumothoraces occurred in five (31.3%) of 16 patients. In 15 (93.8%) of 16 patients, thoracoscopic resection of the targeted nodule was successful; in one patient with dyspnea (6.3%), inaccurate localization resulting in an open thoracotomy occurred because an intervening fissure was not visualized. Dislodgement of the guidewire into the pleural space occurred in one patient (6.3%). The dedicated lung-marker system is a fast and effective method for localization of pulmonary nodules before thoracoscopic resection.

Ultrasound and local anaesthesia. Part III: ultrasound and neuroaxial local anaesthesia

The use of ultrasound as a diagnostic tool for the visualisation of the epidural space has effects on the quality and the performance of epidural anesthesia. This work presents an overview of the recent experiences with ultrasound for epidural anesthesia and on the possibilities for ultrasound imaging techniques. The results of visualisation of the epidural space and its limiting structures obtained by various working groups are presented. We review all presently available data on the prediction of the puncture depth. The various working groups found correlations between predicted and effective puncture depth between 0.79 and 0.98 and the precision of the measurement was 57-7.7 mm. Regarding the prediction of the puncture angle there was a poor correlation ranging between 0.07 and 0.31. The precision between the measured and the punctured angles was found to be 10-13.4 degrees. In all available prospective randomised studies on the puncture effects in the lumbar epidural space, the influence of ultrasound showed a significant reduction ( p<0.03) of the puncture attempts,and we found a significant ( p<0.05) reduction in the number of puncture levels. The ultrasound-guided puncture allowed an ideal needle trajectory and a more precise application of the catheter. A significant improvement of analgesia quality ( p<0.035) and patient satisfaction ( p<0.006) could be achieved. The metaanalysis of the different studies regarding puncture quality by ultrasound-guided peridural anaesthesia showed a clear advantage for the use of imaging techniques.

Image distortion in US-guided liver tumor puncture with curved linear array.

Our objective was to systematically examine the influence of probe geometry, puncture route, and composition of the abdominal wall on the deviation error with needle display. We made a simplified simulation model of the puncture needle passing to the liver tumor, using a microcomputer system, and visualized the degree of distortion of the puncture needle, changing the thickness and component of the abdominal wall as well as the radius of the probe, site, and angle of puncture. The puncture needle exhibited a displacement error of -10.9 to 3.8 mm (center hole) and -11.3 to 3.8 mm (side attachment). The shift was less accentuated when the radius of the probe was large. The displacement error was less accentuated in the center and accentuated in the left side of the field of view. It is recommended that liver puncture under US guidance be generally performed using a probe with a larger radius through the center hole with the most obtuse puncture angle possible, but when the tumor is localized in the hepatic dome, a more tightly curved probe should be used with an acute angle. We must consider a possible large error in display of the puncture needle during liver puncture and try to prevent hazardous complications.

Effects of Blood-Collection Systems and Tubes on Hematologic, Chemical, and Coagulation Tests and on Plasma Hemoglobin

Numerous preanalytical variables may affect the outcome of clinical laboratory tests (1)(2)(3). Blood-collection procedures are considered an important impact factor because they are associated with several possible sampling problems, including the use of a tourniquet with hand-clenching, the site of venipuncture, hemolysis because of venipuncture, and the inappropriate use of sample tubes. In our hospital, two systems are used for venous blood collection: the Becton Dickinson (BD) VacutainerTM system and the Greiner Vacuette® system (Greiner Labortechnik GmbH). The BD product includes a specific blood-collection needle, a holder into which the needle is assembled before phlebotomy, and evacuated blood collection tubes. The Greiner product consists of a sterile holder (Holdex®) with a luer adapter to fit regular needles and evacuated blood collection tubes. The design of the BD needle holder enables direct linear flow of blood from the venipuncture site into the blood collection tubes. The Greiner Holdex was designed with an offset luer adapter to enable a convenient puncture angle. Therefore, the straight path within the Holdex is interrupted twice by angles of 90°, thus forming three consecutive flow segments. These changes in the linear flow of blood might …

Factors influencing pneumothorax rate at lung biopsy: are dwell time and angle of pleural puncture contributing factors?

To study factors that may influence pneumothorax and chest tube placement rate, especially needle dwell time and pleural puncture angle. In 159 patients, 160 coaxial computed tomography (CT)-guided lung biopsies were performed. Dwell time, the time between pleural puncture and needle removal, was calculated. The smallest angle of the needle with the pleura ("needle-pleural angle") was measured. These and other variables were correlated with pneumothorax and chest tube rates. One hundred fifty biopsies were included. There were 58 (39%) pneumothoraces (14 noted only at CT), with eight (5%) biopsies resulting in chest tube placement. Longer dwell times (mean, 29 minutes; range, 12-66 minutes) did not correlate with pneumothoraces (P =.81). Smaller needle-pleural angles (< 80 degrees) [corrected], decreased forced expiratory volume in 1 second to vital capacity ratio (<50%), lateral pleural puncture, and lesions along fissures were associated with higher [corrected] pneumothorax rates (P <.05). Emphysema along the needle path, pulmonary function tests showing ventilatory obstruction, and lesions along fissures predisposed patients to chest tube placement (P <.05). Pleural thickening and prior surgery were associated with lower pneumothorax rates (P <.05). Longer dwell times do not correlate with pneumothorax and should not influence the decision to obtain more biopsy samples. A shallow pleural puncture angle may increase the pneumothorax rate.

EVALUATION OF PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHIC DRAINAGE UNDER ULTRASONOGRAPHY-GUIDED PUNCTURE USING THE NEW NEEDLE WITH CATHETER

We evaluated the indication and problems of percutaneous transhepatic cholangiographic drainage (PTCD) under ultrasonography-guided puncture using the 21G needle with catheter in order to decrease the X-ray radiation to the operator's hands. The catheter of the 21G needle is flexible and we can performed cholangiography and insert guide wires and drainage tubes from outside of X-ray field. By this reason this method of PTCD can decrease X-ray radiation to the hands. These procedures of PTCD were performed in 214 times of 190 patients in our hospital. The punctures of the bile duct were successfully performed in all cases, but insertion of the drainage tube failed in 12 times because of insufficient dilatation under 5mm in diameter and hardness of the bile duct. As a result it is considered that this method is indicated for dilatation of the bile duct over 5mm in diameter and that the suitable angle of puncture and selection of an appropriate catheter are important. The complications in this series were bile duct bleeding in two cases, deviation of the catheter in four cases and serious shock in one case.

Accuracy of liver puncture under US guidance: re-evaluation by microcomputer simulation model.

To evaluate, using microcomputer simulation models, the degree of distortion of the puncture needle in sonograms used during a liver puncture under ultrasound guidance. We made a simplified simulation model of the puncture needle passing through the abdominal wall to the target lesion in the liver (cases without ascites), and additionally through ascites between the abdominal wall and the liver (cases with ascites), to evaluate the degree of distortion of the puncture needle in the sonogram. We considered the thicknesses and sound velocities of the abdominal wall and the ascites fluid, as well as the puncture angle, on the degree of distortion. (1) Cases without ascites: The puncture needle displayed on sonogram shifted predominantly anteriorly with a displacement error between 6 mm forward and 1 mm backward and with an angular error between 2.2 degrees forward and 0.1 degree backward when the abdominal wall was muscular, and the pattern of distortion had an inverted S-shape. It was displayed predominantly posteriorly with a displacement error between 14 mm backward and 2 mm forward and with an angular error between 3.7 degrees backward and 1.2 degrees forward when the abdominal wall was fatty, and the pattern was S-shaped. Regardless of the composition of the abdominal wall, when the abdominal wall was thin, the more obtuse the puncture angle was, the larger the shift was, and when the abdominal wall was thick, the more acute the puncture angle was, the larger the shift was. (2) Cases with ascites: (a) Regardless of the quantity and sound velocity of the ascites, the puncture needle shifted predominantly anteriorly with a displacement error between 7 mm forward and 3 mm backward and with an angular error between 3.1 degrees forward and 1.9 degrees backward when the abdominal wall was muscular, and showed the inverted S-shaped pattern. In contrast, it shifted predominantly posteriorly with a displacement error between 17 mm backward and 5 mm forward and with an angular error between 3.7 degrees backward and 3.9 degrees forward when the abdominal wall was fatty, and showed the S-shaped pattern. (b) Regardless of the sound velocity of the ascites fluid and the composition of the abdominal wall, the shift of the puncture needle changed little with differing amounts of ascites. It is highly recommended that a liver puncture under US guidance be performed taking into account the pattern of distortion of the puncture needle in each situation.

A new laser puncture guidance device for CT- and MRT-guided punctures of the trunk

A stereotactic device was developed to facilitate CT- or MR-guided punctures of the body. The correct needle angulation is checked by the reflection of fan-shaped red and green laser beams upon the needle. Due to its principle of function and design the device has considerable advantages: The puncture angle can be controlled in three dimensions. The freedom of movement within the operation area will not be affected. The device does not have to be permanently installed and can be employed in MRI at any field strength. Furthermore, all kinds of puncture instruments can be used.

Directional needle for antegrade guide wire placement with vertical arterial puncture.

A directional needle with a closed pencil-point tip and a distal side hole was developed to permit antegrade guide wire placement by way of a 90 degrees puncture angle. It has been used in over 25 patients without technical difficulties or complications. It has been very effective for catheterization of the superficial femoral artery for angioplasty, diagnostic studies, and chemotherapy infusion, providing easy antegrade access in patients in whom the traditional antegrade approach may be difficult.