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Management of Visceral Interventional Radiology Catheters: A Troubleshooting Guide for Interventional Radiologists¹

¹ From the Department of Radiology, St Vincent’s University Hospital, Dublin, Ireland. Recipient of a Cum Laude award for an education exhibit at the 2000 RSNA scientific assembly. Received April 19, 2001; revision requested July 6 and received September 18; accepted September 20. Address correspondence to M.M.M., Division of Abdominal Imaging and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, White 270, 55 Fruit St, Boston, MA 02114.

View larger version (86K): [in a new window]   Figure 1a.  Exit of a guide wire through a proximal side hole. (a) Radiograph shows a self-locking pigtail catheter that is unlocked. A straight, stiff guide wire exits through a proximal side hole (arrow). This problem is solved by withdrawing the guide wire back into the shaft of the catheter. An artery forceps is attached securely to the end of the guide wire, thus facilitating torque control. (b) Radiograph shows that the guide wire has been successfully manipulated through the end hole of the catheter.

View larger version (97K): [in a new window]   Figure 1b.  Exit of a guide wire through a proximal side hole. (a) Radiograph shows a self-locking pigtail catheter that is unlocked. A straight, stiff guide wire exits through a proximal side hole (arrow). This problem is solved by withdrawing the guide wire back into the shaft of the catheter. An artery forceps is attached securely to the end of the guide wire, thus facilitating torque control. (b) Radiograph shows that the guide wire has been successfully manipulated through the end hole of the catheter.

View larger version (156K): [in a new window]   Figure 2a.  Exchange of a blocked catheter in a 60-year-old man with bladder cancer in whom bilateral ureteral catheters were placed. (a) Radiograph shows partial occlusion of an 8-F ureteral catheter, which prevents advancement of a guide wire (arrow). (b) Radiograph shows a 9-F peel-away sheath passed over the catheter and into the collecting system. (c) Radiograph shows the catheter straightened within the sheath. The catheter is then withdrawn. (d) Radiograph shows a similar 8-F catheter, which was advanced through the sheath. Good position of the catheter is confirmed with injection of contrast material, and the sheath is removed.

View larger version (148K): [in a new window]   Figure 2b.  Exchange of a blocked catheter in a 60-year-old man with bladder cancer in whom bilateral ureteral catheters were placed. (a) Radiograph shows partial occlusion of an 8-F ureteral catheter, which prevents advancement of a guide wire (arrow). (b) Radiograph shows a 9-F peel-away sheath passed over the catheter and into the collecting system. (c) Radiograph shows the catheter straightened within the sheath. The catheter is then withdrawn. (d) Radiograph shows a similar 8-F catheter, which was advanced through the sheath. Good position of the catheter is confirmed with injection of contrast material, and the sheath is removed.

View larger version (146K): [in a new window]   Figure 2c.  Exchange of a blocked catheter in a 60-year-old man with bladder cancer in whom bilateral ureteral catheters were placed. (a) Radiograph shows partial occlusion of an 8-F ureteral catheter, which prevents advancement of a guide wire (arrow). (b) Radiograph shows a 9-F peel-away sheath passed over the catheter and into the collecting system. (c) Radiograph shows the catheter straightened within the sheath. The catheter is then withdrawn. (d) Radiograph shows a similar 8-F catheter, which was advanced through the sheath. Good position of the catheter is confirmed with injection of contrast material, and the sheath is removed.

View larger version (139K): [in a new window]   Figure 2d.  Exchange of a blocked catheter in a 60-year-old man with bladder cancer in whom bilateral ureteral catheters were placed. (a) Radiograph shows partial occlusion of an 8-F ureteral catheter, which prevents advancement of a guide wire (arrow). (b) Radiograph shows a 9-F peel-away sheath passed over the catheter and into the collecting system. (c) Radiograph shows the catheter straightened within the sheath. The catheter is then withdrawn. (d) Radiograph shows a similar 8-F catheter, which was advanced through the sheath. Good position of the catheter is confirmed with injection of contrast material, and the sheath is removed.

View larger version (53K): [in a new window]   Figure 3.  Unusual reason for difficulty unlocking a pigtail. Photograph shows the locking string wrapped around a catheter, probably because of torque applied during insertion.

View larger version (140K): [in a new window]   Figure 4a.  What to do when the string is left behind. (a) Scout radiograph shows a nephrostomy tube before removal. The tube is cut and withdrawn. (b) Photograph shows that the locking string has been left behind. (c) Photograph shows that the string cannot be removed even by pulling on one end. (d) Photograph shows a 5-F dilator passed over the string and into the tract. The string detaches and is easily withdrawn.

View larger version (157K): [in a new window]   Figure 4b.  What to do when the string is left behind. (a) Scout radiograph shows a nephrostomy tube before removal. The tube is cut and withdrawn. (b) Photograph shows that the locking string has been left behind. (c) Photograph shows that the string cannot be removed even by pulling on one end. (d) Photograph shows a 5-F dilator passed over the string and into the tract. The string detaches and is easily withdrawn.

View larger version (150K): [in a new window]   Figure 4c.  What to do when the string is left behind. (a) Scout radiograph shows a nephrostomy tube before removal. The tube is cut and withdrawn. (b) Photograph shows that the locking string has been left behind. (c) Photograph shows that the string cannot be removed even by pulling on one end. (d) Photograph shows a 5-F dilator passed over the string and into the tract. The string detaches and is easily withdrawn.

View larger version (125K): [in a new window]   Figure 4d.  What to do when the string is left behind. (a) Scout radiograph shows a nephrostomy tube before removal. The tube is cut and withdrawn. (b) Photograph shows that the locking string has been left behind. (c) Photograph shows that the string cannot be removed even by pulling on one end. (d) Photograph shows a 5-F dilator passed over the string and into the tract. The string detaches and is easily withdrawn.

View larger version (103K): [in a new window]   Figure 5.  Catheter fixation technique. Photograph shows the technique for securing a catheter to the skin.

View larger version (120K): [in a new window]   Figure 6a.  How to regain access after a nephrostomy tube has fallen out. (a) Radiograph shows probing of the tract with a hydrophilic guide wire. (b) Radiograph shows the progress of the guide wire along the tract, which is monitored with fluoroscopy. (c) Radiograph shows a 5-F catheter advanced over the guide wire. Contrast material is injected to confirm good position of the catheter within the renal pelvis. The guide wire is then exchanged for a stiffer "exchange" guide wire. (d) Radiograph shows a new catheter, which is placed easily.

View larger version (117K): [in a new window]   Figure 6b.  How to regain access after a nephrostomy tube has fallen out. (a) Radiograph shows probing of the tract with a hydrophilic guide wire. (b) Radiograph shows the progress of the guide wire along the tract, which is monitored with fluoroscopy. (c) Radiograph shows a 5-F catheter advanced over the guide wire. Contrast material is injected to confirm good position of the catheter within the renal pelvis. The guide wire is then exchanged for a stiffer "exchange" guide wire. (d) Radiograph shows a new catheter, which is placed easily.

View larger version (131K): [in a new window]   Figure 6c.  How to regain access after a nephrostomy tube has fallen out. (a) Radiograph shows probing of the tract with a hydrophilic guide wire. (b) Radiograph shows the progress of the guide wire along the tract, which is monitored with fluoroscopy. (c) Radiograph shows a 5-F catheter advanced over the guide wire. Contrast material is injected to confirm good position of the catheter within the renal pelvis. The guide wire is then exchanged for a stiffer "exchange" guide wire. (d) Radiograph shows a new catheter, which is placed easily.

View larger version (110K): [in a new window]   Figure 6d.  How to regain access after a nephrostomy tube has fallen out. (a) Radiograph shows probing of the tract with a hydrophilic guide wire. (b) Radiograph shows the progress of the guide wire along the tract, which is monitored with fluoroscopy. (c) Radiograph shows a 5-F catheter advanced over the guide wire. Contrast material is injected to confirm good position of the catheter within the renal pelvis. The guide wire is then exchanged for a stiffer "exchange" guide wire. (d) Radiograph shows a new catheter, which is placed easily.

View larger version (70K): [in a new window]   Figure 7a.  Catheter kinking in a 45-year-old woman with a large pancreatic pseudocyst. The output from the catheter was reduced. (a) Plain radiograph obtained with the patient in the prone position shows a kink in the catheter (arrow). (b) Radiograph obtained with injection of contrast material after elimination of the kink shows a large cavity.

View larger version (104K): [in a new window]   Figure 7b.  Catheter kinking in a 45-year-old woman with a large pancreatic pseudocyst. The output from the catheter was reduced. (a) Plain radiograph obtained with the patient in the prone position shows a kink in the catheter (arrow). (b) Radiograph obtained with injection of contrast material after elimination of the kink shows a large cavity.

View larger version (135K): [in a new window]   Figure 8.  Situation in which the catheter should come out. Radiograph obtained with injection of contrast material through a catheter positioned in an abscess in the right iliac fossa shows a small cavity with reflux around the tube. In such a case, it is safe to remove the catheter.

View larger version (150K): [in a new window]   Figure 9.  Intermediate case (catheter removal depends on clinical factors). Radiograph obtained with injection of contrast material through a cholecystostomy catheter shows communication with the biliary tract through a patent cystic duct.

View larger version (152K): [in a new window]   Figure 10a.  Situation in which the catheter should not come out. (a) Radiograph obtained with injection of contrast material through a catheter positioned in an abscess in the right iliac fossa shows a large cavity. (b) Radiograph obtained after injection of further contrast material shows opacification of the large intestine (arrows), a finding consistent with a colonic fistula. In such a case, do not remove the catheter.

View larger version (155K): [in a new window]   Figure 10b.  Situation in which the catheter should not come out. (a) Radiograph obtained with injection of contrast material through a catheter positioned in an abscess in the right iliac fossa shows a large cavity. (b) Radiograph obtained after injection of further contrast material shows opacification of the large intestine (arrows), a finding consistent with a colonic fistula. In such a case, do not remove the catheter.

View larger version (160K): [in a new window]   Figure 11.  Positive tractogram. Radiograph obtained with injection of contrast material into the catheter tract shows pleural and peritoneal leakage (arrow).

View larger version (138K): [in a new window]   Figure 12.  Negative tractogram. Radiograph obtained with injection into the catheter tract shows contrast material only within the tract (arrow) with no peritoneal or pleural leakage.

View larger version (90K): [in a new window]   Figure 13.  Pleural effusion after transpleural percutaneous drainage of a postoperative abscess in the left upper quadrant. Radiograph shows a left pleural effusion. It was treated with radiologic placement (under US guidance) of a 12-F radiologic chest drain, which was inserted as close as possible to the point where the abscess drainage catheter transgressed the pleural cavity.

View larger version (115K): [in a new window]   Figure 14a.  Use of pancreatic pseudocyst catheters (transgastric approach). (a) Radiograph obtained with injection of contrast material through the catheter shows a small pseudocyst cavity with reflux along the tract into the gastric lumen. There is no fistula to the pancreatic duct. (b) Radiograph obtained with injection of contrast material through the catheter in another patient shows a small pseudocyst cavity with a communication with the pancreatic duct (arrows). There is reflux along the tract into the gastric lumen. After this study, the catheter fell out, with no adverse results for the patient.

View larger version (113K): [in a new window]   Figure 14b.  Use of pancreatic pseudocyst catheters (transgastric approach). (a) Radiograph obtained with injection of contrast material through the catheter shows a small pseudocyst cavity with reflux along the tract into the gastric lumen. There is no fistula to the pancreatic duct. (b) Radiograph obtained with injection of contrast material through the catheter in another patient shows a small pseudocyst cavity with a communication with the pancreatic duct (arrows). There is reflux along the tract into the gastric lumen. After this study, the catheter fell out, with no adverse results for the patient.

View larger version (115K): [in a new window]   Figure 15a.  Displacement of biliary catheters. (a) Radiograph shows a right-sided internal-external biliary drainage catheter that has backed out of the biliary tract; a segment of the catheter has looped between the liver capsule and the abdominal wall. (b) Radiograph obtained in another patient shows a right-sided biliary catheter that has backed out of the biliary tract and is located in the peritoneal cavity.

View larger version (134K): [in a new window]   Figure 15b.  Displacement of biliary catheters. (a) Radiograph shows a right-sided internal-external biliary drainage catheter that has backed out of the biliary tract; a segment of the catheter has looped between the liver capsule and the abdominal wall. (b) Radiograph obtained in another patient shows a right-sided biliary catheter that has backed out of the biliary tract and is located in the peritoneal cavity.

View larger version (121K): [in a new window]   Figure 16a.  How to reposition a displaced biliary catheter without losing access. (a) Radiograph shows a right-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has looped between the liver capsule and the abdominal wall. The tip of the catheter remains in the biliary tract. The presence of such a loop makes catheter exchange hazardous. (b) Radiograph shows how to advance a guide wire through the loop. The catheter is withdrawn as the guide wire is advanced. (c) Radiograph shows a left-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has formed a loop. (d) Radiograph shows the catheter being withdrawn as the guide wire is advanced.

View larger version (157K): [in a new window]   Figure 16b.  How to reposition a displaced biliary catheter without losing access. (a) Radiograph shows a right-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has looped between the liver capsule and the abdominal wall. The tip of the catheter remains in the biliary tract. The presence of such a loop makes catheter exchange hazardous. (b) Radiograph shows how to advance a guide wire through the loop. The catheter is withdrawn as the guide wire is advanced. (c) Radiograph shows a left-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has formed a loop. (d) Radiograph shows the catheter being withdrawn as the guide wire is advanced.

View larger version (132K): [in a new window]   Figure 16c.  How to reposition a displaced biliary catheter without losing access. (a) Radiograph shows a right-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has looped between the liver capsule and the abdominal wall. The tip of the catheter remains in the biliary tract. The presence of such a loop makes catheter exchange hazardous. (b) Radiograph shows how to advance a guide wire through the loop. The catheter is withdrawn as the guide wire is advanced. (c) Radiograph shows a left-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has formed a loop. (d) Radiograph shows the catheter being withdrawn as the guide wire is advanced.

View larger version (112K): [in a new window]   Figure 16d.  How to reposition a displaced biliary catheter without losing access. (a) Radiograph shows a right-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has looped between the liver capsule and the abdominal wall. The tip of the catheter remains in the biliary tract. The presence of such a loop makes catheter exchange hazardous. (b) Radiograph shows how to advance a guide wire through the loop. The catheter is withdrawn as the guide wire is advanced. (c) Radiograph shows a left-sided external biliary drainage catheter that has backed out along the biliary tract; a segment of the catheter has formed a loop. (d) Radiograph shows the catheter being withdrawn as the guide wire is advanced.

View larger version (159K): [in a new window]   Figure 17a.  Back bleeding from a biliary safety catheter following placement of a Wallstent. (a) Selective celiac arteriogram shows normal arterial anatomy with a biliary catheter, a Wallstent, and a guide wire in place. (b) Arteriogram obtained immediately after the catheter was drawn back over the guide wire during arteriography shows rapid arterial bleeding. Note how the lumen of the Wallstent fills with opacified blood (arrow).

View larger version (159K): [in a new window]   Figure 17b.  Back bleeding from a biliary safety catheter following placement of a Wallstent. (a) Selective celiac arteriogram shows normal arterial anatomy with a biliary catheter, a Wallstent, and a guide wire in place. (b) Arteriogram obtained immediately after the catheter was drawn back over the guide wire during arteriography shows rapid arterial bleeding. Note how the lumen of the Wallstent fills with opacified blood (arrow).

View larger version (132K): [in a new window]   Figure 18a.  Sealing the tract of a biliary catheter with fibrin sealant in a patient with ascites. (a) Radiograph shows a Wallstent, which was placed transpleurally to palliate malignant obstruction of the distal common bile duct. An 8-F Mueller catheter was left in place as a safety catheter. The patient tolerated catheter clamping well. The catheter was removed within 48 hours. Because of the transpleural access and the ascites, radiopaque fibrin sealant (Tisseel; Baxter, Deerfield, Ill) was injected on an empirical basis. (b) Radiograph shows injection of the sealant between the point of entry to the biliary tract and the liver capsule and across the subphrenic space and chest wall. (c) Postprocedure radiograph shows satisfactory position of the sealant (arrow). There were no complications after catheter removal.

View larger version (112K): [in a new window]   Figure 18b.  Sealing the tract of a biliary catheter with fibrin sealant in a patient with ascites. (a) Radiograph shows a Wallstent, which was placed transpleurally to palliate malignant obstruction of the distal common bile duct. An 8-F Mueller catheter was left in place as a safety catheter. The patient tolerated catheter clamping well. The catheter was removed within 48 hours. Because of the transpleural access and the ascites, radiopaque fibrin sealant (Tisseel; Baxter, Deerfield, Ill) was injected on an empirical basis. (b) Radiograph shows injection of the sealant between the point of entry to the biliary tract and the liver capsule and across the subphrenic space and chest wall. (c) Postprocedure radiograph shows satisfactory position of the sealant (arrow). There were no complications after catheter removal.

View larger version (130K): [in a new window]   Figure 18c.  Sealing the tract of a biliary catheter with fibrin sealant in a patient with ascites. (a) Radiograph shows a Wallstent, which was placed transpleurally to palliate malignant obstruction of the distal common bile duct. An 8-F Mueller catheter was left in place as a safety catheter. The patient tolerated catheter clamping well. The catheter was removed within 48 hours. Because of the transpleural access and the ascites, radiopaque fibrin sealant (Tisseel; Baxter, Deerfield, Ill) was injected on an empirical basis. (b) Radiograph shows injection of the sealant between the point of entry to the biliary tract and the liver capsule and across the subphrenic space and chest wall. (c) Postprocedure radiograph shows satisfactory position of the sealant (arrow). There were no complications after catheter removal.

View larger version (101K): [in a new window]   Figure 19a.  Snaring of a ureteric stent by the string of a nephrostomy tube in a patient with pyonephrosis due to a pelvic-ureteric junction stone. The patient was initially treated with antibiotics and percutaneous nephrostomy. Subsequently, the urologist pushed the stone back into the renal pelvis and inserted a ureteric stent from below. (a) Plain radiograph shows a right ureteric stent with a right nephrostomy tube. (b) Radiograph shows that the nephrostomy tube has been removed; however, the string of the nephrostomy tube is snaring the upper end of the stent. (c) Radiograph shows removal of the string by passing a 5-F dilator over one end. The result was successful string removal without stent displacement.

View larger version (95K): [in a new window]   Figure 19b.  Snaring of a ureteric stent by the string of a nephrostomy tube in a patient with pyonephrosis due to a pelvic-ureteric junction stone. The patient was initially treated with antibiotics and percutaneous nephrostomy. Subsequently, the urologist pushed the stone back into the renal pelvis and inserted a ureteric stent from below. (a) Plain radiograph shows a right ureteric stent with a right nephrostomy tube. (b) Radiograph shows that the nephrostomy tube has been removed; however, the string of the nephrostomy tube is snaring the upper end of the stent. (c) Radiograph shows removal of the string by passing a 5-F dilator over one end. The result was successful string removal without stent displacement.

View larger version (154K): [in a new window]   Figure 19c.  Snaring of a ureteric stent by the string of a nephrostomy tube in a patient with pyonephrosis due to a pelvic-ureteric junction stone. The patient was initially treated with antibiotics and percutaneous nephrostomy. Subsequently, the urologist pushed the stone back into the renal pelvis and inserted a ureteric stent from below. (a) Plain radiograph shows a right ureteric stent with a right nephrostomy tube. (b) Radiograph shows that the nephrostomy tube has been removed; however, the string of the nephrostomy tube is snaring the upper end of the stent. (c) Radiograph shows removal of the string by passing a 5-F dilator over one end. The result was successful string removal without stent displacement.