Extravasation of dye

During puncture for pcnl of a pelvic 2.5 cm pelvic calculus, middle calyx puncture.. 1st attempt failed,during 2nd puncture ...dye extravasation occured.. couldn't make out the target calyx now.. intraoperative rgp film attached..

How to proceed or abandon the procedure?

Extravasation of dye


  • Gyanendra Sharma
    Gyanendra Sharma
    02 Apr 2020 12:04:29 PM

    Dear Tkenjit

    What is written below is part written on the same topic in our review article--Fluoroscopic Guided Percutaneous Renal Access
    The link to that article is as follows

    Cause: Extravasation of the contrast is an unfortunate problem. It is important to avoid this situation, as extravasation would happen before the main procedure begins, and would complicate the further access making. The extravasated contrast would make the tract making difficult and also hamper the radiologic confirmation of stone clearance post procedure. The most common cause is when an enthusiastic assistant instills a large volume of contrast under high pressure. Rarely, the contrast may extravasate from an improperly placed ureteric catheter. This would be more common in patients with large impacted ureteric calculi with infection. It may also happen intra-op when the first attempt at needle insertion is not satisfactory and the contrast leaks from the needle puncture site that is made in the collecting system.

    Prevention: To prevent extravasation of contrast, inject diluted contrast slowly while keeping the ureteric catheter in the pelvis so that sudden distension of the system with consequent extravasation does not occur. It is extremely important to instruct the assistant to instill a small amount of contrast gradually at a very low pressure. The volume of the normal collecting system is 5-8 mL; hence gradual instillation of small volume is vital.

    Remedy: The problem can be salvaged in multiple ways: 

    (1) Give diuretic and wait for the contrast to get absorbed. The concentration of the extravasated contrast would significantly reduce if you wait for about 15 minutes after a frusemide injection; 

    (2) Use concentrated contrast that would help in identification of the PCS through the dilute extravasated contrast. The tract needs to be made fast before the concentrated contrast extravasates and compounds the problem; 

    (3) Use of air-pyelogram to identify the PCS. The similar problem of air extravasation can happen through the needle hole in the cortex; 

    (4) Ultrasound guided percutaneous access is a good option. However, even this technique would be difficult after contrast extravasates. Do not attempt air pyelogram, if you want to do an ultrasonography; 

    (5) Very rarely, it may be desirable to stage the procedure and re-attempt access after 48 h; 

    (6) Grasso et al initially described ureteroscopically assisted percutaneous renal access as a salvage procedure in difficult cases. This can be utilized in cases where significant extravasation has occurred. The major hindrance is the availability of a flexible scope, which is not the case in many developing countries; and 

    (7) Giannakopoulos et al have described the use of an angiographic catheter to salvage such situation. A 0.038-inch guide wire is passed through open-end ureteral catheter which is then removed and an angled- tip angiographic catheter is passed. The radiopaque tip of the angiographic catheter is easily seen on the fluoroscopy despite significant extravasation of contrast. A guide wire is then passed through the angiographic catheter. It is manipulated and brought in a calyx which is to be punctured. The angiographic catheter is then brought till the calyx and the puncture is made aiming at the tip of the catheter. The intravenous urogram film or an initial normal fluoroscopic image before extravasation, which is captured on the second monitor of the fluoroscopy unit is very helpful in manipulating the guide wire and catheter in the proper calyx. The correct position of the catheter in a posterior calyx can also be confirmed by rotating the C-arm

  • Abhay Mahajan
    Abhay Mahajan
    02 Apr 2020 09:26:32 PM

    Inject small quantity saline(5-10 ml) for the contrast to clear out. Gently re-inject the contrast after waiting for few minutes. On first fill usually you will be able make out the anatomy of desired calyx. Puncture the calyx & aspirate. Free flow of saline from the needle now will not be seen due to extravasation. Pass a glide wire. If it enters the ureter or coils in the PCsystem, you can dilate the tract further.

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    04 Apr 2020 10:06:27 AM

    Thank u sir...

  • S K PAL
    S K PAL
    06 Jul 2020 07:17:03 PM

    RGP picture displayed here shows extravasation of concentrated contrast. At the outset, we should not use such concentrated contrast in a thin built patient. 

    1.How to decide contrast dilution for an individual patient -
    Dilute 20 cc contrast in 50 ml saline 

    Fill 10 cc of  diluted contrast in a 20 ml syringe

    Just before injecting contrast through ureteric catheter ,Bring this syringe under image intensifier and press the foot switch of C arm very briefly ,just to view and compare the density of contrast as compared to the stone, you are going to remove.

    Density of contrast and stone should be almost equal, or the contrast density should always be less than the density of stone in question. 

    If contrast in syringe appears darker than stone, it should be further diluted and viewed again.

    Even If such diluted contrast gets extravasated during course of making a puncture, at least stone is never out of your vision.

    2. Even If contrast extravasation has occurred once,Tip of ureteric catheter might be outside PCS, or very close to the site of extravasation. 
    Ureteric catheter must be pulled down by 2 to 6 Cms, to the level, where you feel confident that , it must be within PCS, may be in upper ureter. Then first inject bolus of 5 to 15 ml of saline so as to distend the PCS, and then immediately pass a new Terumo glide wire. Watch progress of guide wire. It will reach upto superior or middle calyx and then will coil and take a turn backwards. Fix it there.
    Now make a bull"s eye puncture in the coil of guide wire, while saline is being injected freely through ureteric catheter. Once , you start getting reasonably free outflow of saline from puncturing needle, inject contrast through this needle and your PCS will get opacified adequately. 
    Now select your target calyx and proceed.
    This is  another quite successful method , apart from other techniques described by Dr. Gyanendra Sharma above.

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