Complications of Image-Guided Drainage

Image-guided, minimally invasive drainage procedures have considerably increased in importance over the last decades. In many cases, they have emerged as the preferred option over surgical management of encapsulated collections of fluid—for example, the drainage of abscesses, lymphoceles, hematomas, or bilomas (1). Percutaneous catheter drainage can be performed under guidance by various imaging techniques, such as ultrasonography, fluoroscopy and computed tomography (CT). The decision on the imaging technique to be used depends on factors such as:

• the location of the lesion to be punctured

• the age of the patient

• the skill level of the physician performing the procedure

• the availability of the devices (1).

The aim of our retrospective study was to determine the distribution of percutaneous catheter drainages with regard to anatomical region where the procedure was performed as well as the complication rate based on the data of the registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR, Deutsche Gesellschaft für Interventionelle Radiologie und minimal-invasive Therapie; www.degir.de/qualitaet/degir-qs-register/).

Methods

We performed a multicenter retrospective analysis of anonymized DeGIR registry data from the years 2018–2022. The study included 47 505 patients aged 0–107 years (19 605 women [41.3%], mean age 64.8 ± 16.7 years, and 27 900 men [58.7%], mean age 64 ± 16.1 years) from 226 centers throughout Germany, Austria, and Switzerland who were treated with image-guided percutaneous catheter drainage.

In 1579 cases (3.3%), more than one intervention was performed. The sample included 38 287 CT-guided (79.4%), 6502 ultrasound-guided (13.5%) and 3436 fluoroscopy-guided (7.1%) percutaneous catheter drainages. Complications were ranked A-F according to severity and classified as mild (A-B) or severe (C-F): A) no need for treatment, no sequelae; B) symptomatic treatment and overnight observation, if required; C) need for treatment, short hospital stay (< 48 h); D) need for treatment, unplanned increase in level of care, prolonged hospital stay (> 48 h); E) permanent damage to health; F) death.

Results

In the period from 2018 to 2022, 47 505 image-guided drainages were entered into the registry. Of these, 39,778 procedures were performed within and 7,727 procedures were performed outside the regular working hours of the respective departments.

The majority of procedures were performed on an inpatient basis and only a small proportion were performed on an outpatient basis. Procedures performed on an outpatient basis accounted for 2.5% of the total procedures performed (1 178/47 505).

The largest proportion of all drainages performed were intraperitoneal percutaneous catheter drainages (26.4% [12 523/47 505]) and retroperitoneal drainages (21.5%) [10 206/47 505]) (Table). In addition, drainage catheters were frequently placed in the liver (13.5% [6 420/47 505]) and in fluid collections in the pleural space (14.9% [7077/47 505]). By contrast, needle aspirations were rarely performed in the head region (0.07 % [33/47 505]).

Table. Absolute frequency of image-guided drainage*.

Region of intervention	Number	Complication rate
Head	33	0
Chest	345	0
Lungs	1853	3.45%
Pleura	7077	3.25%
Mediastinum	361	3.05%
Breast	12	0
Gastrointestinal tract	1024	0.88%
Liver	6420	1.89%
Gallbladder	2187	1.33%
Spleen	361	4.71%
Kidney	1395	1.08%
Pancreas	816	1.72%
Peritoneum	12 523	1.11%
Retroperitoneum	10 206	0.89%
Muscle tissue	2601	0.46%
Spine	291	1.03%

*Broken down by region of intervention and relative frequency of complications of each region

Complications occurred in 1.62% (768/47 505) of the percutaneous catheter drainages. The most common complications were pulmonary adverse events (0.75% [357/47 505]), parenchymal hemorrhage (0.19% [91/47 505]) and venous hemorrhage (0.14% [66/47 505]). Spleen (4.71% [17/361] and lung aspirations (3.45% [64/1 853]) were associated with the highest complication rate, followed by needle aspiration of the mediastinum (3.05%; 11/361) (Table). Serious complications occurred in only 0.7% (331/47 505) and minor complications in 0.89% (424/47 505) of percutaneous catheter drainages (Figure). Thirteen complications were not classified. For mild complications, no treatment or only symptomatic treatment is required. Procedure-related deaths occurred in six cases (0.01% [6/47 505]).

Figure.

Proportion of complications of image-guided percutaneous catheter drainage, by complication grade from A-F, of all complications observed

Discussion

In this multicenter, retrospective analysis of registry data from Germany, Austria, and Switzerland from the period 2018–2022, the distribution with respect to anatomical region and complication rate of percutaneous drainage was investigated.

Drainage catheters are recommended for the treatment of a number of abdominal conditions, such as, for example, sigmoid diverticulitis-related abscess (2); however, they are also an alternative to surgery to treat complications following abdominal surgery (3). Thus, percutaneous catheter drainage is most commonly placed intraperitoneally or retroperitoneally.

The anatomical regions with the highest rates of percutaneous drainage-related complications were the spleen (4.71%) and the lungs (3.45%). High complication rates in these organs have been reported previously (4, 5). Nonetheless, the findings of this study overall indicate that percutaneous drainage is a safe procedure. Of 47 505 drains, only 768 procedures were associated with a complication (1.62%). There were more minor (0.89%) than major complications (0.7%), with the latter causing the death of six of 47 505 patients as a result of arterial hemorrhage or cardiac, pulmonary or other complications (0.01%).

Even though this analysis is based on a large number of cases, there are limitations. For example, only DeGIR hospitals were included in the registry and data had to be actively and voluntarily entered into the registry by participating hospitals, which may introduce selection bias, especially in the case of serious complications. The mandatory participation of centers certified by the German Radiological Society (DRG, Deutsche Röntgengesellschaft)/DeGIR suggests an increased representation of interventional specialists. Thus, the risks could be underestimated. Since the DeGIR registry is a radiological registry and many ultrasound-guided interventions are independently performed by other specialties, the proportion of ultrasound-guided interventions is underrepresented.

Conclusion

The results of this study suggest that percutaneous catheter drainage placement by a physician skilled in its use is a safe procedure with a low complication rate. The most common target location of image-guided percutaneous catheter drainages were the peritoneal/retroperitional space. The anatomical regions with the highest complication rates were the spleen and the lungs.