Also, one of the differential considerations was hemangiomas so I was worried about increased risk of bleeding, which prompted me to reach out about this case.


What post or posts were most valuable to you and why? Will you, or have you changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering. Several of the posts were very helpful, particularly the posts from Drs. Worthington-Kirsch and Walworth. These made me more relaxed, as core biopsy seemed less invasive than fragmenting the splenic parenchyma as described. Suggestions for post- procedure bed rest in left lateral decubitus position and additional special procedures, such as tract embolization, also alleviated my concerns. The article link given by Dr. Walsworth also made it easy for me to read the article in my go-to journal, Seminars in IR.


In cases where I am on the fence whether to proceed or not, as happened with this case, this kind of feedback helped the decision-making process and made me comfortable during the procedure. Also, my comfort level regarding future splenic lesions biopsy consults increased.


Additional commentary: Percutaneous image-guided intra-abdominal biopsies are safe, effective and considered one of the most common interventional radiology procedures.1,2,3,4


The indications for intra-abdominal


biopsies include the diagnosis of primary malignancy and other entities such as cysts and infection, tissue sampling for suspected metastases, and malignancy staging.1,2,3


The spleen


is commonly affected in intra-abdominal multiorgan disease; it is an uncommon region for intra-abdominal biopsy relative to the other solid intra-abdominal organs, in part due to perceived hemorrhage risks.4,6


included open splenectomy and laparoscopic splenic biopsy requiring general anesthesia.4


Recent literature—including a


systematic review and meta-analysis on the diagnostic accuracy of percutaneous splenic lesion biopsy—found the use of percutaneous biopsy technique to represent a safe and effective alternative to splenectomy when the spleen was the only site available for biopsy, such as in the case above.5


The choice of imaging modality is based on the anatomic location, size and depth of the lesion of interest, body habitus, and safety of percutaneous access.1,2,3,4


CT and ultrasound are both effective


modalities for lesional characterization and performing biopsy under image guidance.1


imaging and lack of ionizing radiation exposure.2,4


Ultrasound is benefitted by real-time CT provides


cross-sectional anatomical detail and is performed using an overlying grid over the area of interest while measuring shortest distance trajectories from skin entry site to lesion.2,4


For both


modalities, it is important to avoid significant transpleural transgression and minimize the number of passes that are made into the splenic capsule to prevent pneumothorax, pleural space infection, hematoma formation and pain.4


Positioning the


patient in left lateral decubitus position can help displace the ipsilateral lung away from the spleen, creating a safer window for biopsy.4


A breath hold technique can also bring the lesion


into the field of view and mitigate movement that occurs from respiratory motion.1,6


Several needle biopsy tricks may also be


utilized for optimal placement into splenic lesions, including organ hydrodissection and the use of side or end cutting needles with a curved distal end.2


30 IRQ | SUMMER 2022


Clinically significant hemorrhage is a feared, albeit rare, complication of intra-abdominal biopsies, particularly splenic biopsy, and is found in less than 2% of biopsies.1


Thus, many


prior studies have traditionally employed a 20 to 22-gauge for fine needle aspiration or core needle biopsy in order to obviate the risk of hemorrhage.6


The use of 18-gauge side-cutting core


needle biopsies has been described as safe and accurate in a large, recent case series with bleeding rates comparable to kidney and liver lesional biopsies.6


A safety check of vital signs and full


pre-procedure evaluation of labs including complete blood count and INR should be performed prior to lesional biopsy.1,6


Plugging the biopsy tract with Additional


considerations to decrease risk of hemorrhage include reducing ascites with paracentesis or diuretics or correcting any underlying coagulopathies when evident.7


an absorbable gelfoam slurry, which can absorb up to 45 times its weight with whole blood and has minimal risk of non-target embolization, may be employed in patients with higher bleeding risk or when coaxial technique is used.1,7


Polyvinyl alcohol foam,


microfiliary collagen, embolization coils and autologous clot may also be used at the skin entry site and have also been previously described.1,8


Additional quick nontract embolization techniques,


including pressure or tamponade on the percutaneous biopsy skin site, may be performed with the patient lying down on their ipsilateral side.1


In the future, randomized trials assessing the


efficacy of these techniques in providing hemostasis for core and fine needle biopsies may help us better understand their role in preventing bleeding complications.


References


1. Sainani NI, Silverman SG. “Percutaneous abdominal biopsy.” Handbook of Interventional Radiologic Procedures. Kandarpa K, et al. 2016:453-459.


Procedural alternatives historically


2. Sainani NI, Arellano RS, Shyn PB, Gervais DB, Mueller PR, Silverman SG. The challenging image-guided abdominal mass biopsy: Established and emerging techniques. If you can see it, you can biopsy it. Abdom Imaging. 2013;38(4):672–96. doi.org/10.1007/s00261-013-9980-0.


3. Gupta S, Wallace MJ, Cardella JF, Kundu S, Miller DL, Rose SC. Quality improvement guidelines for percutaneous needle biopsy. JVIR. 2010;21(7): 969–75. doi.org/10.1016/j.jvir.2010.01.011.


4. Sammon J, Twomey M, Crush L, Maher MM, O’Connor OJ. Image-guided percutaneous splenic biopsy and drainage. Sem Interv. 2012;29(4):301. doi. org/10.1055/s-0032-1330064.


5. McInnes MD, Kielar AZ, Macdonald DB. Percutaneous image-guided biopsy of the spleen: systematic review and meta-analysis of the complication rate and diagnostic accuracy. database of abstracts of reviews of effects (DARE): Quality-assessed Reviews. Centre for Reviews and Dissemination (UK), 2011. ncbi.nlm.nih.gov/books/NBK91784/.


6. Nirav P, Dawe G, Tung K. Ultrasound-guided percutaneous splenic biopsy using an 18-G core biopsy needle: Our experience with 52 cases. Br J Radiol Suppl. 2015;88(1055): 20150400. doi.org/10.1259/bjr.20150400.


7. Tsang WK, Luk WH, Lo AXN. Ultrasound-guided plugged percutaneous biopsy of solid organs in patients with bleeding tendencies. Hong Kong Med J. 2013. doi.org/10.12809/hkmj133972.


8. Handke NA, Koch DC, Muschler E, Thomas D, Luetkens JA, Attenberger UI, Kuetting D, Pieper CC, Wilhelm K. Bleeding management in computer tomography-guided liver biopsies by biopsy tract plugging with gelatin sponge slurry. Scientific Reports. 2021;11(1):24506. doi.org/10.1038/ s41598-021-04155-1.


Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.


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