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411

Case

Percutaneous Endoluminal

Extraction Sonography

Steven

S. Garra,

V. Lossef,1

Brian

Klemens

of Biliary H. Barth,

and Robert

During percutaneous retrieval of retained biliary duct calculi, blood clots or focal submucosal hematoma can mimic and sometimes obscure small stones and stone fragments. With the recent availability of catheter-based, miniaturized endoluminal sonography systems, it may be possible to distinguish

focal

submucosal

intraluminal

hematoma

stone.

This

and intraluminal

hypothesis

undergoing percutaneous extraction common bile duct via a T-tube track.

Case

was

clot from

tested

an

in a patient

of a stone

from

the

catheter-based

echogenic,

a 9-mm shock-wave

woman

bile duct.

retained

stone

lithotripsy

had a cholecystectomy Subsequent

T-tube

in the common fragmented

and exploration

cholangiography

bile duct.

the stone,

with

of

sonographic

nonshadowing

subsequent

pas-

MHz probe mounted on a 4.9-French catheter (Diasonics, Milpitas, CA), which was inserted over a steerable 0.0i4-in. (0.37-mm) guidewire. A small echogenic filling defect with acoustic shadowing was detected when the tip of the probe was positioned at the level of the suspected stone (Fig. i B). No other echogenic structures were seen. After extraction of the stone with a stone basket, cholangiography showed a new focal filling defect along the medial aspect of the distal portion of the common hepatic duct (Fig. iC). As the possibility of a residual stone or fragment in this location could not be excluded, the

minal sonography

August

1992 0361 -803X/92/1

March 3, 1992. University Hospital,

592-041

It showed

a non-

at the level of the filling

of the entire biliary tree did not show any other

shadowing intraluminal filling defects. Several small, nonshadowing intraluminal defects were present; these were interpreted as small blood clots. An access catheter was inserted at the end of the procedure. A follow-up cholangiogram 2 weeks later showed no residual intraluminal filling defects. The submucosal defect in the partial

of the common

resorption

the patient

hepatic

of hematoma.

has been

duct was smaller, The

asymptomatic

catheter

was

consistent

removed,

and

for 8 months.

3800

Discussion Percutaneous fluoroscopically

system,

1 © American

Roentgen

extraction by injecting

and it is usually

of stones is typically monitored contrast material into the biliary

possible

to determine

when

all

fragments have been extracted. The presence of blood clots, submucosal hematoma, or air bubbles or extrinsic compression by vessels can obscure this endpoint. Although air bubbles appear echogenic on intraluminal sonograms, they tend

to have more reverberations and less distinct shadows than stones have. Moreover, bubbles can usually be flushed away or removed by gravity drainage, allowing fluoroscopic differentiation

from

hematoma

Reservoir

Ad.

Lossef. AJR 159:41 1-412,

was reinserted.

showed

was injected into the biliary tree, defect in the common bile duct was performed by using a 20-

Received January 2, 1992; accepted after revision 1AII authors: Department of Radiology, Georgetown

probe

mural structure

Extracorporeal

sage of all but one 5-mm particle. After 6 weeks, the stone was extracted percutaneously. A i 3-French sheath was placed within the T-tube track, and contrast material showing a focal intraluminal filling (Fig. iA). Endoluminal sonography

of

defect (Fig. 1 D). This was considered to be more compatible with a focal submural hematoma, presumably from local trauma caused by the catheter, rather than a residual stone fragment. This was later confirmed by sweeping the bile duct with a Fogarty balloon. Intralu-

with

A 59-year-old

Value

K. Zeman

distal portion

Report

the common

Stones:

Report

Ray Society

residual

stones.

Persistent

may be more difficult

,

NW.

,

Washington,

DC 20007.

clot or submucosal

to distinguish

Address

reprint

fluoroscopi-

requests

to S. V.

412

LOSSEF

ET AL.

AJR:159, August

Fig.

1.-Percutaneous

Downloaded from www.ajronline.org by 222.133.29.22 on 10/21/15 from IP address 222.133.29.22. Copyright ARRS. For personal use only; all rights reserved

stone in a 59-year-old

extraction woman. shows retained

of

1992

biliary

A, Cholangiogram stone (ar. row) in common bile duct Guidewires (arrowheads) were inserted through limbs ofT-tube. B, Intraluminal sonogram shows echogenic, intraluminal calculus with prominent shadowing (large arrow), sonographic probe (open arrow), and guidewire (small arrow).

C, Cholangiogram shows persistent filling defeet (arrow) after stone extraction. 0,

Intraluminal

sonogram

obtained

after

C

shows nonechogenic, nonshadowing structure consistent with intramural hematoma (h). Echoes (arrows) are from guidewires.

cally. In our case, the lack of echogenicity and acoustic shadowing ofthe residual mural lesion allowed us to terminate

echogenicity of structures such as the ureter, urethra, ducts, intestine, and fallopian tubes. Using endoluminal

the extraction

nography, Goldberg et al. [4] were able to localize renal calculi smaller than the bile duct calculus we imaged.

procedure

with

some

assurance

fragments had been retrieved. Fluoroscopic guidance is recommended

that

during insertion

the sonographic transducer to verify that the tip beyond any suspicious intraluminal filling defects. should then be obtained while pulling the probe should minimize the possibility of inadvertently

stone ahead of the transducer,

preventing

all stone

of

is inserted Sonograms back. This pushing a

angioplasty,

atherectomy,

that endoluminal

to fluoroscopy

presence

of

residual

sonography

for evaluating fragments

after

may be a useful

the biliary tree for the extraction

of

biliary

stones.

detection.

Miniaturized probes for endoluminal sonography have been used for intravascular evaluation. Applications have included examination of the lumen of the aorta and iliac arteries [1]; monitoring results of transluminal vascular procedures, includ-

ing balloon

We conclude

adjunct

bile so-

stent

insertion,

and

laser angioplasty recanalization [2]; and evaluation of thrombi in the inferior vena cava [3]. Goldberg et al. [4] reported nonvascular uses of miniaturized endoluminal sonography probes in experimental animals and indicated that the probes could be used to accurately measure luminal thickness and

REFERENCES 1 . Nishimura

2.

RA, Welch TJ, Stanson AW, Sheedy PF, Holmes DR. Intravascular US of the distal aorta and iliac vessels: initial feasibility studies. Radiology 1990;176:523-525 Isner JM, Rosenfleld K, Losordo DW, et al. Percutaneous intravascular US as adjunct to catheter-based interventions: preliminary experience in patients with peripheral vascular disease. Radiology 1990;175:61-70

3. McCowan evaluation

TC, Ferns EJ, Carver DK. Inferior vena caval filter thrombi: with

intravascular

US. Radiology

1990;177:783-788

4. Goldberg BB, Liu JB, Morton DA, Kurtz AB. Endoluminal US: experiments with nonvascular uses in animals. Radiology 1990;175:39-43