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Real-time CT Fluoroscopy: Evolution of an Interventional Tool¹

¹ From the Department of Radiology, University of Maryland Hospital, 22 S Greene St, Baltimore, MD 21201-1595. Received July 7, 1998; revision requested August 27; revision received October 2; accepted November 25. Address reprint requests to B.D.

View larger version (115K): [in a new window]   Figure 1. For biopsy or for access needle placement under continuous CT fluoroscopic guidance, a stainless steel sponge forceps (arrow) is currently our needle immobilization device of choice. This reduces secondary radiation scatter to the operator's hands.

View larger version (161K): [in a new window]   Figure 2. Multiple images (1–9) from a low-dose (30-mA) CT fluoroscopy sequence during biopsy of a lung nodule in the lingula (arrow). The patient could not cooperate with breath holding. Real-time CT imaging allowed successful biopsy and avoidance of the adjacent heart. Histologic examination revealed adenocarcinoma.

View larger version (116K): [in a new window]   Figure 3. Multiple CT fluoroscopic images obtained during mediastinal biopsy in a patient with suspected recurrent mediastinal seminoma. Biopsy of a subtle lesion (arrow) in the aortopulmonary window was performed by using a transsternal approach with intermittent low-dose (50-mA) CT fluoroscopy to check needle position. Real-time observation of breathing was used to select the optimal phase of respiration to puncture the mediastinum. Direct manual pressure was necessary to effect transsternal placement. Biopsy yielded benign tissue.

View larger version (160K): [in a new window]   Figure 4a. Ethanol ablation of hepatocellular carcinoma. (a) Initial conventional helical image demonstrates tumor recurrence (arrow) following surgical resection. (b) During table movement and ethanol injection, sequential low-dose (50-mA) CT fluoroscopic images (1–6) demonstrate distribution of ethanol within the lesion (arrows). Most of the low-attenuation ethanol has been retained within the pseudocapsule of the tumor. Three needles have been inserted into the lesion. (c) CT scan 4 months later demonstrates shrinkage and absence of enhancement in the lesion (arrow), indicating successful treatment.

View larger version (158K): [in a new window]   Figure 4c. Ethanol ablation of hepatocellular carcinoma. (a) Initial conventional helical image demonstrates tumor recurrence (arrow) following surgical resection. (b) During table movement and ethanol injection, sequential low-dose (50-mA) CT fluoroscopic images (1–6) demonstrate distribution of ethanol within the lesion (arrows). Most of the low-attenuation ethanol has been retained within the pseudocapsule of the tumor. Three needles have been inserted into the lesion. (c) CT scan 4 months later demonstrates shrinkage and absence of enhancement in the lesion (arrow), indicating successful treatment.

View larger version (141K): [in a new window]   Figure 4b. Ethanol ablation of hepatocellular carcinoma. (a) Initial conventional helical image demonstrates tumor recurrence (arrow) following surgical resection. (b) During table movement and ethanol injection, sequential low-dose (50-mA) CT fluoroscopic images (1–6) demonstrate distribution of ethanol within the lesion (arrows). Most of the low-attenuation ethanol has been retained within the pseudocapsule of the tumor. Three needles have been inserted into the lesion. (c) CT scan 4 months later demonstrates shrinkage and absence of enhancement in the lesion (arrow), indicating successful treatment.

View larger version (117K): [in a new window]   Figure 5. Chemoneurolysis of superior hypogastric nerve plexus for relief of pelvic pain from disseminated rectal carcinoma. With use of real-time guidance, a 20-gauge needle was inserted through the small bowel into the presacral space below the aortic bifurcation. A retroperitoneal approach was not possible due to bilateral ureteric stents (arrowheads). 1–3, Low-dose (50-mA) CT fluoroscopic images show initial contrast material and alcohol injection at the needle site. 4–6, Images obtained during table movement demonstrate caudal to cranial spread of low-attenuation alcohol (arrow) and high-attenuation contrast material–anesthetic mixture in the presacral space. The patient's symptoms improved following this procedure.

View larger version (163K): [in a new window]   Figure 6a. Percutaneous gastrostomy. (a) Digital anteroposterior radiograph shows the high position of the stomach (arrow) following extensive surgery; this position made an endoscopically or conventional fluoroscopically guided gastrostomy problematic in this patient. (b) Six images from a low-dose (50-mA) CT fluoroscopy sequence demonstrate successful placement of an access needle into the stomach (S). The remainder of the procedure was also performed by using CT fluoroscopic guidance.

View larger version (128K): [in a new window]   Figure 6b. Percutaneous gastrostomy. (a) Digital anteroposterior radiograph shows the high position of the stomach (arrow) following extensive surgery; this position made an endoscopically or conventional fluoroscopically guided gastrostomy problematic in this patient. (b) Six images from a low-dose (50-mA) CT fluoroscopy sequence demonstrate successful placement of an access needle into the stomach (S). The remainder of the procedure was also performed by using CT fluoroscopic guidance.