Volume 28, Issue 1, March 2025, 101022Author links open overlay panel, , ,

Recent developments in cancer genomics have allowed for comprehensive genomic profiling of tumors, thereby allowing oncologists to provide targeted therapies for patients with advanced cancers. This has made it even more important to obtain adequate core biopsies of lesions targeted for biopsies. While most lesions can be biopsied safely percutaneously using CT and ultrasound guidance, some lesions do not have a safe percutaneous window, thereby necessitating alternative biopsy techniques, such as transvenous biopsies, to aid in diagnosis and treatment. This review explores the use and technique of the transvenous approach for targeting small abdominal and pelvic masses using intravascular ultrasound guidance.

Introduction

Recent developments in cancer genomics have allowed for comprehensive genomic profiling of tumors, thereby allowing oncologists to provide targeted therapies for patients with advanced cancers. Additionally, with an increase in the incidence of cancer globally, it has become even more important to obtain adequate tissue samples when performing biopsies.1 Unfortunately, not all lesions have a safe percutaneous window to proceed with a percutaneous biopsy, posing a grave diagnostic challenge.

While nontargeted solid organ biopsies such as renal and liver biopsies have been safely performed using the transvenous approach, recent advances in intra-vascular imaging over the last decade have allowed us to safely and accurately biopsy small abdominal and pelvic lesions precisely via transvenous approach using side firing Intravenos Ultrasound (IVUS) also known as Intra-Cardiac Echo (ICE), lesions which otherwise may not have a safe percutaneous window.

Recent studies have shown that transvenous targeted biopsies are safe to perform and have diagnostic accuracy (greater than 90%) comparable to targeted percutaneous biopsies performed using CT guidance.2,3 In this review, we will discuss the patient selection criteria, technique, and outcomes of transvenous biopsies as a problem-solving tool.

Section snippetsPatient selection

All patients requiring a biopsy are evaluated in the preprocedural setting, either as an outpatient in the Interventional Radiology (IR) clinic or in the inpatient setting where the procedure benefits, risks, and alternatives are discussed. Many of the patients have already undergone detailed cross-sectional imaging such as a CT scan or MRI of the abdomen or pelvis. In case the patient has not undergone cross-sectional imaging, authors recommend obtaining a CT Abdomen Pelvis with intravenous

Preprocedure work up

The authors recommend preprocedure work up and obtaining basic labs such as complete blood count (CBC), basic metabolic panel (BMP) and international normalized ratio (INR) per providers institutional policy.5 The need for the type of sedation – moderate sedation versus general anesthesia can be determined based on patient co-morbidities and operator preference and expertise. Authors recommend holding anticoagulation based on individual institutional guidelines for a high-bleeding risk

Technique and equipment

The procedure is performed under direct fluoroscopic guidance with the use of side-firing IVUS (ICE). The patient is brought to the procedure room and placed supine on the table. After following institutional protocol for presurgical checklist completion/time out and induction of anesthesia/sedation, the patient is prepped and draped in a sterile fashion.

Transvenous biopsies can be performed via the Internal Jugular Vein (IJ) or Common Femoral Vein (CFV) access, based on the location of the

Technical considerations

Sampling can be repeated as needed using the same steps until an adequate volume of tissue is obtained for the needed histopathologic testing.

Once sampling is complete, the operator can perform venography to confirm no extravasation is present, though this may not be a necessary step in cases where the lesion encases the vein.4 The needles, wires, catheters, and sheaths can then be removed from the patient. Hemostasis is achieved by manual compression and sterile dressings are applied.

Case 1

A 35-year-old female with a past medical history notable for systemic lupus erythematosus (SLE) and obstructive uropathy secondary to retroperitoneal fibrosis presents with a growing retroperitoneal soft tissue lesion encasing the inferior vena cava (IVC) and aorta. The lesion had previously been biopsied percutaneously with just FNA (fine needle aspirate); however, the FNA samples were ultimately nondiagnostic.

Due to the vascular involvement, no safe percutaneous window was identified to

Outcomes and complications

Transvenous biopsies have proved to be an invaluable tool for sampling lesions with no safe percutaneous window, but just like percutaneous biopsies, transvenous biopsies carry a risk of bleeding, infection and injury to the surrounding structures as well as obtaining a nondiagnostic sample. There is also a theoretical risk for track seeding, although it has not been well documented in the literature yet.4

Several studies have shown that transvenous biopsies are safe and have a diagnostic yield

Declaration of competing interest

The authors have no relevant financial disclosures or other conflicts of interest.

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