A case of percutaneous deep pelvic abscess drainage using CT fluoroscopic guided cranio-caudal puncture technique

Abstract

A 52-year-old male patient presented with complaints of abdominal and back pain. CT revealed a deep pelvic abscess extending into the anterior sacral space. Since puncture via the conventional transgluteal approach cannot reach a deep abscess, percutaneous pelvic abscess drainage was performed under CT fluoroscopy using the cranio-caudal puncture technique. The cranio-caudal puncture requires needle insertion perpendicular to the CT cross-section. This method advances the CT gantry deeper than the needle tip and follows the CT cross-section with the needle tip. This series of images and movements continues until the needle reaches the target. The procedure was successful without complications, the abscess was reduced in size, and blood test data improved. The cranio-caudal puncture technique provides an alternative for the drainage of deep pelvic abscesses that avoids the complications associated with gluteal muscle puncture. Percutaneous drainage of pelvic abscesses under CT fluoroscopy-guided cranio-caudal puncture offers a safe option as a puncture route for deep pelvic abscesses.

Keywords: Axial puncture; CT fluoroscopy; Cranio-caudal approach; Pelvic abscess; Percutaneous drainage.

Fig. 1

Preoperative CT of the pelvic abscess. Preoperative CT shows an abscess in the presacral space (A, arrow), with the upper edge extending to the level of the sacral superior border (B, arrow). This area is surrounded by pelvic bones (B), making a transgluteal approach difficult.

Fig. 2

A representation of the start of the puncture using a phantom. The puncture is started at the point where the skin surface intersects the puncture line assumed from CT performed before the puncture. The positioning light helps confirm the starting point for the puncture.

Fig. 3

Procedures for C-C punctures. The methods proceeds chronologically from ⅰ) to ⅵ). i) Place the cursor in the abscess cavity on the CT monitor during the positioning phase of (A-C). Scroll down the slice to the surface of caudal skin plane with the arrow-shaped cursor in place. Ensure that there are no structures to be avoided in the area through which the arrow-shaped cursor passes. ii) Start the puncture using the arrow-shaped cursor position in (C) as a landmark. The high-density point drawn at the intersection of the 2 white dashed lines in (F) is the puncture needle. The image in (F) is a cross-section at the same level as in (C). iii) Shift the fluoroscopic slice in the head direction (B) and check again that there is no obstruction. iv) Advance the needle until the puncture needle appears on the fluoroscopic plane. The puncture needle is the dense dot drawn at the intersection of the 2 white dashed lines in (E). The image in (B) is a cross-section at the same level as (E). Similarly, by repeatedly rechecking the slightly cephalic section (v) and inserting the needle, the needle finally reaches the abscess cavity (vi).

Fig. 4

CT and radiographic images after placement of the drainage tube. A drainage tube is placed via a caudal approach using C-C puncture. The tip (A, arrowhead; B arrowhead) is successfully inserted near the upper border of the sacrum within the abscess (A, arrows).