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The posterior intercostal approach for percutaneous renal procedures: Risk of

puncturing the lung, spleen, and liver as determined by CT

Article in American Journal of Roentgenology · February 1990

DOI: 10.2214/ajr.154.1.2104692 · Source: PubMed

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 115

The Posterior Intercostal

Approach for Percutaneous Renal
Procedures: Risk of Puncturing the
Lung, Spleen, and Liver as Determined
byCT

Kenneth D. Hopper1’2 A posterior intercostal approach is commonly used for percutaneous access to the
Wayne F. Yakes2 upper poles of the kidney. However, the safety of this approach with respect to
puncturing the intervening lung, pleura, liver, and spleen with the needle has been
inferred only from a small series of patients without regard to the degree of respiration.
To determine the possibility of puncturing these structures, we performed CT at both
maximal inspiration and expiration and with sagittal reconstructions in 43 (27 supine
and 16 prone) randomly selected patients. With expiration, the needle path was such
that there was little risk to the spleen and liver from an 1 lth-l2th posterior intercostal
approach. However, the chance of transgressing the lung with this approach to the
kidney was 29% on the right and 14% on the left. If done during maximal inspiration,
the lung would be in the path of the needle in most patients. With a 10th-I Ith rib
posterior intercostal approach, the chance of puncturing the lung was excessive regard-
less of the degree of respiration used.
Our results show that the primary risk from a posterior 1 lth-l2th rib intercostal
approach to the upper renal collecting system is puncture of intervening lung, a
complication that can be expected to occur in from 14% to 29% of patients. The risks
from a posterior 10th-i ith rib intercostal approach appear prohibitive.

AJR 154:115-117, January 1990

The posterior intercostal approach is frequently used for access to the upper
pole renal calix for a variety of interventional procedures. This route is especially
important when attempting to extract upper-pole staghorn calculi or to gain
entrance to the ureter, such as for stent placement. To study the safety of this
technique, we determined the potential path of the needle on CT scans obtained
in 43 patients during both full inspiration and expiration and with the patient either
supine or prone. The chance of the lung, liver, and spleen being in the path of the
needle inserted by a posterior intercostal approach was determined.

Subjects and Methods

Received January 30, 1989; accepted after re- Eighty-six CT scans were performed on 43 patients, 25-86 years old (25 men, 18 women)
vision August 3, 1989. undergoing both unenhanced and enhanced CT of the abdomen for evaluation of various
The opinions or assertions contained herein are clinical problems. Informed consent was obtained, and sequential 1 0-mm sections were
the private views of the authors and are not to be made. Patients with upper abdominal diseases that could affect anatomic relationships were
construed as official or as reflecting the views of
excluded. Contrast material was administered orally in each patient.
the Department of the Army or the Department of
Defense. Twenty-seven supine patients and 1 6 prone patients each had two CT scans, one in full
1 Department of Radiology, The Milton S. Her- inspiration and the other in full expiration. Bilateral sagittal reconstructions were done through
shey Medical Center, The Pennsylvania State Uni- the kidneys in all patients, and the vertical angles between the horizontal plane and a line
versity, P.O. Box 850, Hershey, PA 17033. Address drawn from the upper pole of the kidney to the upper margin of the 11 th and 1 2th ribs and
reprint requests to K. D. Hopper. the inferior margins of the lung, liver, and spleen were measured (Fig. 1 ). The upper renal
2 Diagnostic Radiology Service, Department of pole was defined as the most cephalad calix as seen on CT. Positive angles indicate that the
Radiology, Fitzsimons Army Medical Center, Au- structure is cephalad to the upper renal pole. A negative angle indicates that the structure is
rora, CO 80045-5001.
caudad to the upper renal pole. From the vertical angles, the safety of a posterior intercostal
0361-803X/90/1541-01 15 approach to the upper renal poles was calculated (Table 1).
116 HOPPER AND YAKES AJR:154, January 1990

Results pronounced on the right side, where the average angle de-
In the supine patient, the angle between the horizontal and creased approximately 25#{176}
(Fig. 3). By comparing the poste-
lines drawn between the upper pole renal calix and the lower rior sagittal angles of the 1 1 th-1 2th and 1 0th-i 1 th rib inter-
margin of either the spleen or liver did not change significantly spaces to the edge of the lung, liver, and spleen, the risks
between inspiration and expiration (right side, 50#{176} to 49#{176};left from an intercostal approach were calculated (Table 1).
side, 57#{176}to 53#{176}).However, in the prone patient, these angles In most prone patients, intervening lung poses the greatest
changed appreciably. The posterior vertical angle between risk from percutaneous intercostal procedures into the upper
the upper right renal pole and the hepatic edge decreased renal pole. For example, an 1 1 th-i 2th intercostal approach
from 65#{176}with inspiration to 53#{176}with expiration. The posterior into either upper renal pole would not be expected to puncture
vertical angle between the upper left renal pole and the splenic intervening spleen or liver if done during expiration. However,
edge decreased from 56#{176} during inspiration to 50#{176} during this approach during expiration would traverse lung in 29%
expiration. of percutaneous procedures on the right side and in 14% of
In the supine patient, the angle between the upper renal procedures on the left side. These same approaches, if done
pole and the lung edge did not change significantly between during inspiration, would puncture intervening lung in 86% of
inspiration and expiration (right side, 42#{176} to 48#{176};left side, 37#{176} patients on the right side and 79% of patients on the left side.
to 38#{176}).
However, in the prone patient, the lung moved much The increased risk from a 1 0th-i i th rib prone intercostal
more cephalad in expiration (right side, -21 #{176} to +5#{176};left side, approach into either upper renal pole is significant. If done
4#{176}
to 23#{176})
than did the upper renal pole, causing an 18#{176} (left with the patient in full expiration, the liver would be punctured
side) to 26#{176} (right side) increase in posterior sagittal angles in 1 4% of patients and the spleen in 33% of patients. More
(Fig. 2). seriously, however, the right lung is transgressed in 86% of
The phase of respiration had little effect on the relationship patients and the left lung in 93% of patients. These percent-
between the upper pole calix and the 1 ith and 1 2th ribs in ages are summarized in Table 1.
either the prone or supine patient. However, there was a
significant difference in the prone vs supine patient in that the Discussion
kidney moved farther cephalad with respect to the lower ribs.
The posterior intercostal approach is commonly used to
This more cephalad renal position in the prone patient caused
gain access for percutaneous interventional procedures in-
a decrease in the measured sagittal angle. This was more
volving the kidney [1-6]. The puncture is usually made below
the 1 1 th and less commonly below the 1 0th rib [4]. A frequent
concern is the transgression of lung and/or pleura by cathe-
ters 8-French and larger. Using this approach in 50 patients,
Picus et al. [3] noted that 8% of their patients had a pleural
effusion and 4% had a pneumothorax. According to our data,
when patients are prone and in full expiration, needles inserted
Fig. 1.-Verticalangles were via an intercostal approach between the 1 1 th and 1 2th ribs
measured sagittally from hori- would be expected to puncture the left lung in 1 4% and the
zontal plane of most cephalad
right lung in 29%. On the other hand, Clayman and Casta-
renal calix to inferior edges of
liver, spleen, and lung and to #{241}eda-Zu#{241}iga
[6] reported only a 6% frequency of hemothorax
tops of 11th and 12th ribs. In or pneumothorax from this intercostal approach. Diaphrag-
this diagram, vertical angle to
left costophrenic angle is dis-
matic and/or pleural puncture appear inevitable with an inter-
played. Spine is to right. costal approach because they both partially insert onto the

TABLE 1: Posterior Sagittal Angles About the Upper Renal Poles (Chance [%] That Structure
Will Not Be in Path of Needle)

Right Side Left Side

Structure Supine Prone Supine Prone

Inspir Expir Inspir Expir Inspir Expir Inspir Expir

Lung below liver/spleen 59 52 1 00 93 80 65 80 80
Lung above liver/spleen 41 48 0 7 20 35 20 20
1 1 th-1 2th rib approach safe from
Pleura 70 70 14 14 74 74 21 21
Lung 70 92 14 71 74 84 21 86
Liver/spleen 89 85 1 00 1 00 96 1 00 87 100
10th-i ith rib approach safe from
Pleura 28 28 7 7 33 33 7 7
Lung 37 28 7 14 33 36 7 7
Liver/spleen 48 46 93 86 76 74 80 6
Lung below 12th rib 15 7 27 20 0 4 13 67

Note-Percentages are based on the 1 6 patients scanned at full inspiration (Inspir) and expiration (Expir), both
supine and prone. The upper renal pole is defined as the highest CT section with an opacified calix.
 Fig. 2.-A and B, Sagittal reconstruction
CT scans in a prone 55-year-old
of
man in plane of r ,‘
left kidney during inspiration (A) and expiration
(B). A needle inserted into renal calix of left
upper pole via an 1 lth-I2th intercostal approach
during expiration would not pass through lung or
spleen (s). However, if inserted during inspira-
tion, lung would be traversed. A IOth-llth inter-
costal approach would result in puncture of lung
in both inspiration and expiration. Spine is to
right. 12 = 12th rib; 11 = 11th rib.

Fig. 3.-A and B, Sagittal reconstruction of

CT scans in plane of right kidney in a 69-year-
old man. Right lung extends to bottom of the
12th rib during inspiration (A). With expiration
(B), kidney moved cephalad with respect to 12th
rib. Lung, however, moved farther cephalad,
making a percutaneous puncture in expiration
via an 1 lth-l2th intercostal approach less likely
to transgress lung. Spine is to right.

1 2th rib. Indeed, with deep inspiration in the prone position, In conclusion, posterior intercostal approaches into the
it is sometimes possible to inflate the lung to the bottom of upper kidneys appear to have little risk from intervening liver
or below (Fig. 3) the 1 2th rib (Table 1). Of course, the and spleen when performed with the patient in full expiration.
complications of intercostal approaches would be potentially The increased morbidity from this approach is primarily related
greater with catheter placement than with a small needle. In to the posterior lung. It can be expected that the pleura is
addition, a more lateral catheter placement poses a greater trangressed asymptomatically in most of these patients. If
risk to the colon, liver, and spleen [7, 8]. this approach is done when the patient is in mid or full
Our data show that at full expiration, the risk of puncturing inspiration, the risk to the liver, spleen, and especially the lung
the liver or spleen is minimal when needles are inserted via is much increased. The risks from a 1 0th-i 1th intercostal
the posterior 1 lth-i 2th rib intercostal approach, whereas the approach appear prohibitive regardless of the degree of res-
lung is at risk in 1 4% to 29% of punctures. Some authors [6] piration used.
recommend the intercostal puncture be done with the patient
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