The safe intercostal approach? Pleural complications in abdominal interventional radiology

Six serious pleural complications (three empyemas, two hemothoraces, and one bilious effusion) have occurred after use of the right intercostal approach to the upper abdomen in 230 interventional radiologic procedures performed over the last 3 years. The anatomy of the pleural reflection in the right costophrenic sulcus is reviewed and correlated with a dissection study of the course of right intercostal needle punctures in three cadavers. The pleural reflection reaches the level of the 10th rib in the midaxillary line, and in the cadaver study, all 9th- 10th interspace punctures clearly traversed pleura, diaphragm, and peritoneum to reach the liver. The widely held belief among radiologists that the pleura can be deliberately avoided in transhepatic cholangiography and biliary drainage is shown to be false. It is believed that most needle punctures traverse the costophrenic sulcus, through pleura but below lung, despite the low incidence of reported pleural complications. a left subxiphoid approach avoiding the pleura is recommended in patients with abscesses, ascites, emphysema, anxiety, and, in the case of biliary drainage, benign or purely left-sided disease. When using the intercostal approach, the minimum number of needle passes, careful route planning, antibiotic prophylaxis, and postprocedural chest radiography are strongly recommended.