1. ULTRASOUND & CT

2. Puncture sites
Access:
•Meticulous guiding ultrasound exam.
- Shortest skin-target distance
- Avoid blood vessels, biliary tree, bowel
- Use Doppler may be helpful
- Once access decided:
Test respiratory training (deep or shallow) with short apnea to simulate
biopsy moment
Advantages of US:
- Real-time visualisation of the target.
-Good visualisation of the access window.
- Real-time progression of the needle with possible modification of the trajectory.

3. Interventional
Ultrasound
Always Avoid  AVOID IF POSSIBLE 
Large vessels,  Bowel 
proximal organ vessels Liver 
!Ureter  Distal vessels 
Gallbladder 
Parenchymatous 
organs:kidney, spleen,
pancreas

4. CONDITIONS OF REALISATION
One day Hospitalization
(Outpqtient (if cooperative, family at home, classical technique
Fasting
Clinical and imaging data
platelets >150 000 -
PT >70 %s -
TCA < 2x Normal -
.Stop anticoagulant TTT 8 days before
Sedation - anxiolytic 2 hours before
!!No sleeping patient

5. ULTRASOUND
(.Cleaning of probe, keyboard and cable (protocol 
Select probe and application depending on procedure 
(Try to choose sectorial view if linear probe is used) 


6. INTERVENTIONAL PROCEDURE
Skin antispetic measures by technician according to
protocol
Patient covered with sterile field
Sterile material on sterile table
Cover the US probe with sterile protection

7. INTERVENTIONAL PROCEDURE
(Local Anesthesia (10 à 20 cc Lidocaïne 1% 
IM or LP needle according to depth of the target
Evaluation of the trajectory-
!Take care of air in the syringe-
If liver biopsy go to capsule -
(Needle guide (US/TDM 
anesthesia
(Skin deep incision with scalpel axis //ribs (intercostal artery 

8. GUIDANCE METHOD
Biopsy Kit :
Adaptable systeme on the probe: visualization of target and
needle trajectory
“ Free-hand” Technique :
Probe is positioned at the entry point with needle along axis of
US beam allowing visualisation of the whole length of the trajectory
(abdominal).
Always visualize your entry path
with real-time needle progression

9. GUIDANCE METHOD
Always prefer Free-hand technique 
possibility of orientation adjustment
at last minute and angle of skin
penetration. Once capsule is
traversed no more adjustment
possible: withdraw and redress your
angle
Needle aligned in the axis of US 
beam to visualize its swhole length
If you loose trajectory move probe 1 
or 2 degrees/ needle then scree with
probe in Doppler mode to search
needle

10. GUIDANCE METHOD
Always prefer Free-hand 
technique
Needle aligned in the axis of US 
beam to visualize its swhole length
If you loose trajectory move probe 1 
or 2 degrees/ needle then scree with
probe in Doppler mode to search
needle

11. Interventional Ultrasound
Lateral decubitus
Intercostal approach! Scalpel Orientation when doing skin incision

12. Needles
Many varieties
Different sizes, calibers, form, shape and nature of the procedure
• Cytology : Chiba needle, Franseen
• Histology : Bard needle

13. Needles
Many varieties

14. Interventional Ultrasound
’If solid mass : biopsy 18/16 G ‘True cut 
If cystic mass : initial Fine Needle Aspiration 
(FNA)-Don’t empty-wall biopsy
If possible do microbiopsy (histology) of the 
wall

15. Co-axial’ Technique‘
types : co-axial - tandem 2 
Coaxial : 1 large bore needle (19G) in contact with the lesion ; 
multiple samples taken with smaller and longer needle inserted
(within it (20G
Advantage : One puncture with multiple samples (<hemorragic
( risk but only one direction
Tandem : 1 needle in the lesion ; biopsy needle parallel 
Advantage : trajectory already done and multiple directions of
biopsy

16. Interventional Ultrasound
Automatic needle: one action movement 
Progression with needle tip visualisation during 
apnea
Adjust needle length 
If gun is used consider length of specimen
((wall/necrosis
Specimens 3 
Change needle (FNA / microbiopsy) depending on 
tissue obtained
•Biopsy of normal liver also

17. Liver
Increased hemorragic risk if hemangioma puncture 
Fill the needle track with Gelfoam 

18. Interventional Ultrasound
Possible puncture of distal portal or hepatic branches 
.Biopsy subcapsular lesion by penetration through normal liver 
Use respiration to move the diaphragm and keep away the pleuram 
recess from the needle to get below it
Coaxial Technique 

19. GUERIDON PRELEVEMENT
Sterile table 
gauze 1 
(ampoule of normal saline (moisten biopsy 1 
bottle of Formol or wet gauze 1 
If drainage : tubes of bacteriology for culture & sensitivity 

20. DEALING WITH SPECIMENS
:BIOPSIES LIVER KIDNEY LYMPH NODES PANCREAS OR ABDOMINAL MASS
(1st time : place on gauze then wet with normal saline (during puncture 
. 2nd time : Place in formol 
: FNA OR COLLECTION DRAINAGE
.Aspiration with syringe then put aspirate in sterile tube for bacteriological studies 

21. COMPLICATIONS
Complications are rare (0,008% à 0,03 %)
-Vasovagal attack
Severe complications
- hemorrhage, arterio-veinous fistula, hematoma and
pneumoperitoneum (liver)
- Acute pancreatitis if normal pancreatic tissue
- Metastatic seeding of the needle track.