Drainage Catheter Placement - Imaging guidance

Overview

Image-guided percutaneous drainage catheter placement has largely replaced open surgical drainage for most accessible fluid collections, 97% of intra-abdominal abscesses are now drained percutaneously. The principles apply across anatomical regions (thoracic, abdominal, retroperitoneal, pelvic) and success depends on meticulous pre-procedure imaging review, appropriate guidance modality selection, catheter sizing and management, and vigilant post-procedure monitoring. This objective also encompasses radiologically inserted enteral access tubes (nasogastric, nasojejunal, nasoduodenal) and percutaneous gastrostomy/gastrojejunostomy.

Indications

Percutaneous Drainage of Fluid Collections

General principle: indicated for an accessible collection in a patient who does not require immediate surgery, or where drainage serves as a temporising/adjunctive measure. Collections ≤1-3 cm may respond to antibiotics alone; larger or complex collections warrant drainage (antibiotic penetration is limited in established collections).

Radiologically Inserted Enteral Access Tubes

Contraindications

Percutaneous Drainage

Percutaneous Gastrostomy / Enteral Access

Imaging Guidance Modalities

Small-bore drains (12-14 Fr) are at least as efficacious as large-bore drains for free-flowing pleural effusions, pleural infection, and uncomplicated pneumothorax, with lower complication rates and improved patient comfort.

Catheter Placement Techniques

Seldinger Technique

Sequential needle → wire → serial dilator → catheter placement. Preferred for deep or complex collections where controlled deployment reduces risk of posterior wall transgression. Facilitates catheter placement in collections with tough fibrous walls.

Tandem-Trocar (Direct Puncture) Technique

Faster; no serial dilation required; metal stiffener aids directionality. Best for superficial, large, unilocular collections. Caution: thick fibrous walls may deflect the catheter; a malpositioned catheter will typically require withdrawal and replacement.

Catheter Sizing Principles

General Principles to Minimise Complications

• Use the safest, most direct, shortest percutaneous route
• Avoid intervening organs and vital structures
• Place catheter in the most dependent portion of the cavity
• Use an angled approach
• Cross one body cavity to drain another only when absolutely necessary
• Thorough pre-procedural imaging review is mandatory before all drainage procedures

Post-Procedure Catheter Management

Expected Post-Drainage Appearances

• Interval reduction in collection size on follow-up CT or US
• Catheter tip in most dependent portion of cavity
• Mild pericatheter soft tissue stranding is expected
• Air in a previously fluid-only collection may indicate bowel communication (fistula) or introduced during placement

Catheter Management Principles

• Daily flushing (10-20 mL normal saline) to maintain patency
• Monitor daily output volume and character
• Catheter removal criteria: output $\leq 10$ mL/day for $\geq 3$ consecutive days; clinical resolution (apyrexia, normalised inflammatory markers); imaging confirmation of collection resolution
• Established tract forms approximately 2-4 weeks after catheter placement; catheter dislodgement within this period requires urgent replacement

Troubleshooting Low Output With Persistent Collection

Persistent high-volume output raises suspicion for fistula formation (biliary, pancreatic, enteric, urinary). Confirm with contrast injection through the catheter under fluoroscopic guidance. Catheter must remain in situ until fistula resolves. Upstream diversion (surgical or endoscopic) should be considered where necessary.

Specific Drainage Procedures

Percutaneous Cholecystostomy

• Indications: Acute calculous or acalculous cholecystitis (including empyema gallbladder) in high-risk surgical patients; biliary tract access for intervention. Emergency cholecystectomy mortality in patients >65 years is ~13.3% (vs 1.3% elective); rises to ~25% with empyema.
• Contraindications: Decompressed gallbladder; interposed bowel; uncorrectable coagulopathy (relative); malignancy
• Approach: Transhepatic (preferred, theoretical tamponade of bile leak) or transperitoneal; US ± fluoroscopy guidance
• Technical success: 95-100%; clinical improvement (fever, leukocytosis, pain) within 2-3 days in 68-100%
• Complications: Catheter dislodgement (most common; 6.1-14%); bile leak; haemobilia; vagal reaction; procedure-related complications in 0-26.3% (usually minor)

Percutaneous Nephrostomy (PCN)

• Indications: 1. Obstructive uropathy (calculus, tumour, stricture) with or without infected hydronephrosis 2. Pyonephrosis 3. Urinary leakage or fistula 4. Access for interventional/endoscopic procedures: ureteric stenting, PCNL, stone dissolution, antibiotic delivery, foreign body retrieval, biopsy 5. Urinary diversion for haemorrhagic cystitis
• Contraindication: Uncorrectable coagulopathy
• Guidance: US-guided initial puncture into appropriate lower pole posterior calyx; contrast injection confirms collecting system position; fluoroscopy for wire/catheter advancement
• Accepted major complication thresholds (ACR/SIR/SPR):

• Catheter fixation: self-retaining locked pigtail suture + skin suture + tape wrap ("Roman sandal" configuration); definitive management (e.g. ureteric stenting) should not be delayed

Deep Pelvic Collections

• Pre-procedure CT review is mandatory
• Access routes: transgluteal (avoids bowel; risk to sciatic nerve/gluteal vessels), transperineal, transvaginal, transrectal
• Transvaginal/transrectal approach for deep collections inaccessible anteriorly; dedicated US needle guide required
• Crohn's perianal disease: favour transabdominal or transgluteal approach (transrectal route risks complex fistula formation)
• Prostate/periprostatic abscess: transrectal US-guided 18-G needle aspiration to dryness preferred over catheter drainage; pigtail catheter via Seldinger technique if pus is thick

Subphrenic Collections

• Subcostal approach preferred to avoid transgressing pleural space
• If intercostal approach unavoidable, enter as caudal as possible to minimise risk of pleural effusion/empyema
• Post-procedure monitoring for pleural complications is essential

Infected Walled-Off Pancreatic Necrosis (WON)

• Step-up approach is current standard of care (PANTER trial and subsequent RCT data): initial minimally invasive percutaneous drainage, escalating to minimally invasive or surgical necrosectomy only if drainage fails
• Left anterior pararenal/paracolic retroperitoneal approach preferred for lesser sac collections (reduces peritoneal contamination); transperitoneal if no retroperitoneal window
• Large-bore catheters preferred (facilitate drainage of necrotic debris; reduce blockage)
• Follow-up CT within 48 hours to 1 week of drain placement to assess drainage adequacy, residual debris, undrained collections, and catheter position
• Lack of clinical improvement (recurrent fever, persistent SIRS >48 hours, leukocytosis, new/persistent organ failure) is an indication for catheter upsizing, additional drainage, or surgical/endoscopic necrosectomy
• Transcatheter contrast injection under fluoroscopy is important to assess pancreatic duct communication; if ductal communication confirmed, endoscopic pancreatic duct stenting should be attempted

Percutaneous Gastrostomy and Enteral Access

PRG: Push vs Pull Method

Both methods are performed primarily under fluoroscopic guidance; CT is used as an adjunct in difficult cases. A nasogastric tube (or 5-Fr angiographic catheter if NG placement is not possible) must be pre-placed to insufflate the stomach. Oral contrast 1 day prior delineates colonic loops. Access is generally left of midline over the gastric antrum/mid-distal body.

Push method (T-fastener gastropexy):

1. Gastropexy with T-fasteners (3-4 fasteners) placed under fluoroscopy to approximate stomach to anterior abdominal wall; confirmed on lateral view
2. Central 18-gauge needle puncture; air aspiration confirms intraluminal position; contrast injection confirms placement
3. 0.035-inch stiff guidewire insertion; serial fascial dilation via peel-away sheath
4. Balloon-retention gastrostomy tube placed (14-20 Fr); position confirmed with contrast injection (rugal fold opacification)

Pull method:

1. Single gastric puncture under fluoroscopy
2. Hydrophilic guidewire and catheter navigated retrograde through GEJ and oral cavity
3. Exchange for stiff guidewire; gastrostomy tube pulled antegrade through abdominal wall (mushroom-retention type)

Post-procedure care:

• Catheter to gravity drainage for 24 hours; feeds commenced gradually at 24 hours if no peritonitis (fever, abdominal pain, tenderness, absent bowel sounds)
• Full nutrition generally achieved within 48 hours

Technical success: 95-100%; procedure-related mortality 0-3.2%

Gastrojejunostomy Tube

• Indications: Gastro-oesophageal reflux, aspiration risk, large gastric residuals (feeding beyond the ligament of Treitz)
• Primary placement or conversion of existing gastrostomy (conversion can be technically challenging depending on initial tube angulation)
• Angled 5-Fr catheter + hydrophilic guidewire navigated through pylorus into jejunum; exchange for stiff wire; GJ tube placed after tract dilation
• Primary placement success: 95-100%

Percutaneous Jejunostomy

• Indications: Failed GJ tube conversion; abnormal stomach position; chronic aspiration with gastric outlet obstruction; dislodged surgical jejunostomy tube
• Proximal jejunal loop insufflated via nasojejunal tube; puncture under fluoroscopy with contrast to confirm intraluminal position; Cope sutures or T-fasteners fix jejunum to abdominal wall; 14-Fr locking pigtail catheter via Seldinger technique
• Technical success: 85-95%
• Complications: Minor, localised pain, puncture site infection, tube blockage; major, pericatheter leakage, peritoneal spillage

Percutaneous Cecostomy

• Alternative to surgical cecostomy in patients unfit for general anaesthesia
• Primary indication: decompression of dilated caecum at risk of perforation (perforation carries mortality up to 50%)
• Performed under local anaesthesia and sedation

Complications

Early Complications

Late Complications

Reporting Structure

A structured report for percutaneous drainage should address:

1. Clinical indication and relevant pre-procedure imaging findings
2. Guidance modality (US, CT, fluoroscopy, or combined)
3. Access route and approach
4. Technique (Seldinger vs tandem-trocar)
5. Catheter size and type (e.g. 12-Fr locking pigtail)
6. Confirmation of position (contrast injection findings; degree of collection decompression)
7. Initial output (volume and character: purulent, serous, bilious, haemorrhagic)
8. Immediate complications
9. Follow-up recommendations (clinical monitoring, imaging follow-up timing, catheter management instructions)

Limitations

• Highly viscous collections (organised necrosis, haematoma) may not drain adequately through standard pigtail catheters; large-bore tubes, irrigation, or surgical intervention may ultimately be required
• Multiloculated collections often require multiple catheters or catheter repositioning
• Collections adjacent to bowel, major vessels, or in difficult anatomical locations (lesser sac, deep pelvis) may lack a safe percutaneous window
• Fistulating collections (pancreatic, biliary, enteric) typically cannot be definitively treated with drainage alone; upstream diversion is usually required
• Infected tumours: catheters often cannot be removed and may remain long-term or until surgical tumour removal; MDT discussion is mandatory before proceeding
• Colonic interposition may preclude standard anterior gastrostomy approach; may be overcome with CT guidance or alternative access planning
• Paediatric patients require operator experience and appropriate small-calibre equipment

Key Pitfalls

Sources

• ACR Appropriateness Criteria (American College of Radiology)
• NICE guidance (National Institute for Health and Care Excellence, UK)