Pericardial Drain Placement in Interventional Radiology: An Overview

Abstract

Pericardial effusions can occur from multiple different etiologies. Although often incidentally noted or clinically silent, pericardial effusions may cause significant hemodynamic compromise. In some of these patients, pericardiocentesis may be temporizing only and either repeat procedures or placement of pericardial drains may be preferable. While cardiologists typically perform pericardial drain placement, it is a procedure that may also be performed by interventional radiologists. This article describes for the interventional radiologist the indications and placement technique, as well as potential complications occurring from pericardial drain placement.

Since the first needle pericardiocentesis was performed by Franz Schuh in 1840, percutaneous drainage of pericardial effusions has evolved from a blind procedure to an ultrasound (US)-guided procedure in the late 1970s. This conversion to imaging guidance has improved patient safety and is currently considered the standard of care. ¹ Evolving from simple pericardicentesis, the indwelling pericardial catheter for continuous drainage of pericardial effusion refractory to multiple isolated pericardiocentesis was first reported by Massumi et al in 1964 and then in 1975 by different cardiologists. ^{2 3 4} Pericardial catheter placement is typically currently being performed by interventional cardiologists, interventional radiologists, or thoracic surgeons with distribution varying by institution. ^{5 6 7} In additional to an US-guided approach, pericardiocentesis can also be performed under fluoroscopy, computed tomography (CT), and/or electrocardiography (ECG) guidance. For example, fluoroscopy is useful during wire placement, while US is more effective in establishing the extent of effusion and ideal needle trajectory; both can be helpful in guiding needle placement. ⁸ Complication rates have been shown to be similar between US and fluoroscopic guidance while performing pericardiocentesis alone. ⁹ CT may better assess the nature and extent of pericardial effusions and disease compared with US, but catheter placement under CT guidance comes at the expense of increased procedural time and radiation. Bishop et al initially described the use of ECG as a safeguard in pericardiocentesis in 1956 when the procedure was usually performed without direct imaging guidance. ¹⁰ For this approach, the pericardiocentesis needle is connected to a precordial ECG lead with visualization of ST and PR segment elevation used as indicators of epicardial needle contact. However, this method can be limited by medications, pericarditis, ventricular hypertrophy, ischemia, and infarction which can also alter ST segments. ¹¹

Pathologies Treated

Directly analogous to pleural fluid, pericardial serous fluid is continuously produced from the parietal and epicardial capillaries and drained by the epicardial lymphatic system. Physiological amounts of fluid within the pericardial sac average between 20 and 25 mL/day, with a range of 20 to 60 mL. ¹² For various reasons, pericardial effusions can develop between the visceral and parietal pericardium when there is increased production and/or impaired drainage of fluid. It can develop rapidly requiring urgent decompression, or gradually allowing the normal pericardium to accommodate up to 2 to 3 L of fluid. ¹ Regardless of how quickly the effusion develops, acute or chronic pericardial effusions can lead to cardiac tamponade when intrapericardial pressure is high enough to impede venous return and impair cardiac filling. Etiologies, and the frequency with which they are seen, vary widely between populations studied. The most common etiologies include malignancy, iatrogenic injury, infection, idiopathic, and blunt or penetrating chest trauma. Malignancies that cause pericardial effusions mostly originate from the lung and breast, ¹³ while infectious etiologies are commonly from viruses or mycobacterium. ¹⁴ Over the past two decades, iatrogenic causes have become more common with complications caused by increased percutaneous coronary and intracardiac interventions. ¹⁵

Other Treatment Options

In addition to the treatment of the underlying cause of the effusion (such as anti-inflammatory medications for viral pericarditis or antituberculosis medications for tuberculous pericarditis), transient pericardial effusion without cardiac tamponade can be treated conservatively with close serial hemodynamic monitoring and volume repletion. ¹⁶ Cardiac tamponade with hemodynamic compromise requires urgent decompression with percutaneous pericardiocentesis or surgical creation of a pericardial window. A pericardial window can be created with open surgery, under video-assisted thoracoscopy, or percutaneously using balloon-assisted pericardiotomy. ^{16 17} This window creates a communication between the pericardial space and the pleural cavity, and allows for continuous drainage of pericardial effusion into the chest cavity.

Placement of a percutaneous pericardial indwelling catheter is a less invasive option for patients with recurrent pericardial effusions that are refractory to repeat pericardiocentesis. This procedure also allows for continuous rather than intermittent pericardial effusion drainage. It is also ideal for patients with high general anesthesia risk either due to the pericardial effusion itself or underlying cardiopulmonary decompensation; such contraindications preclude the patient from surgical pericardial window creation. For recurrent malignant pericardial effusions refractory to both percutaneous pericardial indwelling catheter and surgical pericardial window creation, Schroeppel DeBacker et al described a percutaneous approach for the placement of an indwelling pericardial–pleural double pigtail drain by puncturing the intervening pericardium and pleura under fluoroscopy and CT guidance. ¹⁸ Pericardial sclerosis with sclerosing agents may be another option for malignant effusion refractory to indwelling catheter placement alone. Although there is a theoretical risk for constrictive pericarditis, ¹⁹ limited retrospective studies demonstrated similar overall median survival times between patients with malignant effusions who underwent pericardial catheter placement with a sclerosing agent and other drainage methods. ^{20 21}

Patient Selection

Patient selection for pericardial drain placement is key to successful completion of the procedure and improved clinical outcomes. Emergent indications include the presence of hemodynamic changes with suspected cardiac tamponade physiology, particularly when there is concern for recurrence. Nonemergent indications include hemodynamically stable patients in whom the catheter is placed for diagnostic, palliative, postsurgical, or prophylactic reasons. Regardless of etiology, catheter placement can be performed utilizing anatomic landmarks, or image guidance with fluoroscopic, CT, or US guidance.

The most common nonemergent indication for pericardial drain placement is recurrent malignant pericardial effusion; catheter placement is particularly beneficial in patients presenting with cardiac tamponade. Tamponade physiology is typically detected by echocardiography, and suspected when there is abnormal septal motion, right atrial to right ventricular inversion, and decreased respiratory variation of the diameter of the inferior vena cava. Pertinent clinical examination findings for cardiac tamponade include Beck's triad (hypotension, distant heart sounds, and jugular venous distension) and pulsus paradoxus (decrease in systolic blood pressure of more than 10 mm Hg with inspiration caused by a reduction in cardiac output during inspiration). Contraindications to pericardial drain placement include aortic dissection, myocardial rupture, and traumatic effusion with hemodynamic instability, as these etiologies warrant immediate surgical correction. In these populations, however, pericardiocentesis and/or pericardial drain placement may be performed to stabilize the patient prior to definitive surgical procedures. ²² For cardiac tamponade after trauma (usually blunt chest trauma), emergent thoracotomy is recommended. ²³

Technique

There are several ways by which drains can be placed into the pericardial space. Radiologists tend to place them using either US or CT guidance, while cardiologists often use either US (echocardiography) and/or electrocardiographic guidance. Depending on the clinical setting, adjuvant use of fluoroscopy to advance the catheter over a wire may be helpful but is not completely necessary. For an excellent overview of pericardial drains placed under CT guidance, please see the How-I-Do-It article by Inger et al in this issue of Seminars .

While drainage catheters can be placed with the patient in the supine position, this typically requires a large effusion without septations. In some instances, particularly in patients with malignant or infected collections, fluid can be loculated and the nondependent fluid collection may be minimal in size. Since access is obtained in this nondependent collection (or at least not entirely in the dependent portion), having a fluid predominantly in the nondependent pericardial space makes the initial needle puncture more difficult and potentially riskier.

Particularly in this setting, a second way by which a pericardial catheter can be placed is using US guidance with the patient in an upright position. Similar to placement of a chest tube in this position, placing the patient upright in their bed allows fluid to shift to the lower (more caudal) portion of the pericardial space. When using the standard subxiphoid approach, having the patient upright and slightly leaning forward facilitates initial placement of the needle.

There are benefits and drawbacks to using each of the techniques described here. Having the patient in the supine position can be performed more easily in patients requiring sedation, allows for the use of fluoroscopy in placing the catheter over a wire, and there is no significant difference in using this technique than placement of any other drainage catheter. A major drawback is that in patients who are hemodynamically unstable, they may become worse in the supine position (although placing the patient with their head elevated 30–45 degrees may be beneficial). The benefit of performing the procedure with the patient upright is largely the reason described earlier, that is, the fluid collects in the dependent portion of the pericardial sac. Drawbacks include the fact that fluoroscopy cannot be used; patients must be hemodynamically stable and relatively cognitively intact; the operator must perform the procedure differently in that the angles used in needle puncture and catheter and wire manipulations may be more awkward; and the patient must be largely awake during the procedure (and watching the procedure unless shielded in some way from the field of view). The technique used is largely operator and patient specific—understanding both techniques allows for tailoring of the procedure based on individual variables.

For either procedure, the subxiphoid approach is typically used. Particularly for large effusions, the subxiphoid approach allows for access into the pericardial sac with minimal cardiac motion and a low risk of inadvertent cardiac puncture. While it may be that the largest pocket of fluid is visualized by a left-sided intercostal or subcostal approach, initial puncture of the pericardial fluid can be performed nearly anywhere the pocket is largest and accessible. This may be particularly applicable to patients with malignant effusions or hemopericardium, where fluid may be septated or loculated. A specific added risk of approaches other than the subxiphoid approach is the possibility of transgression of the pleural space, which is rarely, if ever, seen with the latter.

Once access into the pericardial sac is obtained, a small amount of fluid is aspirated to confirm needle placement. Particularly in patients with hemopericardium or malignant effusions, the aspirate may appear to be frank blood. This finding may cause angst for the proceduralist, causing concern for intracardiac puncture. Real-time imaging of initial needle placement, and fluoroscopic or US visualization of wire advancement, will allay those concerns (plus the fact that puncture of the right ventricular wall would require placement of the needle to be very deep and met with significant resistance to advancement). Once needle placement into the pericardial sac is obtained, standard over-the-wire technique is used to place a pigtail drainage catheter. The authors prefer to use a catheter with a smaller pigtail (e.g., Dawson-Mueller; Cook Medical Inc., Bloomington, IN); however, nearly any basic drainage catheter can be used. For transudative effusions, an 8- to 8.5-Fr catheter is sufficient; for bloody or malignant effusions, a larger catheter may be necessary.

Constant EKC and hemodynamic monitoring is essential during all aspects of the procedure, but particularly during wire manipulations. Although typically transient, persistent dysrhythmias may occur and should be prepared for. Once the catheter is placed and good position confirmed by US and/or fluoroscopy, it is secured to the skin. The authors prefer to use a suture with a mesentery—multiple knots tied in the suture between the skin and catheter—to allow some motion of the catheter during the normal cardiac cycle.

Outcomes

Most pericardial effusions can be successfully treated with catheter drainage, but this procedure may be unsuccessful for loculated effusions, clotted blood, subacute effusive–constrictive pericarditis, or significant recurrences after initial drainage. Technical success is defined as uneventful percutaneous access into the pericardial space with successful drainage of fluid via a drainage catheter with subsequent relief of symptoms and/or tamponade physiology. Technical success rates range from more than 95 to 99%. ^{24 25} The complication rate is approximately 1 to 3%, with a mortality rate of less than 1%. Complications resulting in death typically occur from injury directly caused by the procedure, particularly uncorrectable dysrhythmias, or myocardial puncture. ⁵ There may be more procedural complications following surgical drainage of pericardial effusions than there are with pericardial drain placement, and if the fluid is drained via pericardiocentesis the need for repeat procedures may be greater, depending on the need for fluid removal. ²⁶

Complications

Potentially serious complications can occur with pericardiocentesis and pericardial drain placement with rates reported between 4 and 20%. ^{24 27 28} The most feared complication is cardiac perforation, but this is rare occurring at a rate of approximately 1%. ²⁵ This occurs most often in the right ventricle when using the anterior subxiphoid. Bleeding from a right ventricular puncture is often not severe due to the chambers relatively low pressures; however, the thin right ventricular wall is vulnerable to laceration, which if not recognized may lead to substantial bleeding and return to tamponade physiology with transition into hemodynamic shock. Cardiac dysrhythmias may occur, usually demonstrated as ectopic atrial or ventricular beats most often occurring if the needle is in direct contact with or perforates the myocardium. Although less common, sustained dysrhythmias are also possible. Other complications include coronary arterial injury, most commonly when utilizing a subxiphoid approach and most often the right coronary artery given its anatomic location anteriorly in the interventricular groove. The left anterior descending artery and its branches can similarly be injured during an apical approach. Additional complications may include vascular injury to any artery in the path to the pericardium, including the internal mammary artery (consideration in a parasternal approach) and inferior phrenic arteries (consideration in a subxiphoid approach). Other rare but serious complications include hemothorax, pneumothorax, pneumopericardium, and surrounding visceral injury. Additional pitfalls to consider during and following catheter placement include false-negative aspiration (clotted blood in the pericardium), false-positive aspiration (intracardiac aspiration), and reaccumulating of pericardial fluid and return to tamponade physiology.

Summary

Although typically performed by cardiologists, pericardial drain placement can also be performed by interventional radiologists by using standard imaging and over-the-wire catheter techniques. This procedure may be life-saving, particularly when performed in the acute setting. Knowledge of the anatomy, procedural details, and potential complications is necessary for the IR performing these procedures.