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Seldinger Technique

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0:01

Sven, uh, Sellinger is, uh, our friend who,

0:04

uh, invented this technique,

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you know, with respect to the vascular system,

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but it is the exact same technique.

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So let's unpack this bad boy.

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Okay, so the first thing we do is we get a needle

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to essentially say, you know what, I got my

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little needle here, I got my imaging guidance.

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So, we'll use ultrasound for

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the sake of comparison here.

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And so, I know exactly, sort of,

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wherewhere the skin is, which is what I have

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to start as my origin, departure.

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Departure, destination.

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Destination being the abscess.

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And I gotta, I gotta get

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7.4 ccentimeters.

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So maybe I'm going to start with a little UE

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20 00:00:41,065 --> 00:00:42,755 Centesis Needle, okay, which has a little

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sharp stylet, kind of like a little bevel

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tip, and then it has a little outer catheter.

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It comes in often sort of

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7 centimeters and 10 centimeters.

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So I was like, alright,

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let me use the 10 centimeters one.

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That'll give me a little distance.

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So, got that marked out.

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So then I'm going to get

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in there, boom, I'm inside.

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And so then, once I'm inside, I do the

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exact same thing that we did in the trocar

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technique, where we say, oh, you know

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what, let's aspirate, alright, because,

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who knows what this is.

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This may be a hematoma, whatever.

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So let's go ahead and aspirate that fluid.

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We got the fluid out, sucked out.

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So now we're in.

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Looks yellow, smells like pus, it's pus, okay?

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So let's move on now.

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So now we're inside, we

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confirm, destination, pus.

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This is where we want to be

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with our life at this moment.

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So let's go ahead and send the

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wire in, and we call this wire in.

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So nice if we're using a Benson wire, which

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usually has about 7 centimeters of a floppy tip.

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So we get that 7 centimeters to coil, and then

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it kind of hits and stops at that nice sort

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of solid portion of the wire.

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And then we sort of maintain

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that as a little railroad, okay?

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So then we take out the access catheter,

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in this case perhaps a USES and TESIS

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needle, USES and TESIS catheter, and

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then we say, okay, well now we're in.

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And so the next step may be to say, alright,

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after we sort of place that guide

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wire, now we may want to dilate, right?31 00:00:58,405 --> 00:01:00,205 And so then, once I'm inside, I do the

1:00

exact same thing that we did in the trocar

1:02

technique, where we say, oh, you know

1:03

what, let's aspirate, alright, because,

1:05

who knows what this is.

1:07

This may be a hematoma, whatever.

1:08

So let's go ahead and aspirate that fluid.

1:10

We got the fluid out, sucked out.

1:12

So now we're in.

1:14

Looks yellow, smells like pus, it's pus, okay?

1:19

So let's move on now.

1:19

So now we're inside, we

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confirm, destination, pus.

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This is where we want to be

1:25

with our life at this moment.

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So let's go ahead and send the

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wire in, and we call this wire in.

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So nice if we're using a Benson wire, which

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usually has about 7 centimeters of a floppy tip.

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So we get that 7 centimeters to coil, and then

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it kind of hits and stops at that nice sort

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of solid portion of the wire.

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And then we sort of maintain

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that as a little railroad, okay?

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So then we take out the access catheter,

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in this case perhaps a USES and TESIS

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needle, USES and TESIS catheter, and

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then we say, okay, well now we're in.

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And so the next step may be to say, alright,

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after we sort of place that guide

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wire, now we may want to dilate, right?

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Right?

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So we say, okay, we need to go from this five

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French catheter to an eight French,

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or what I prefer is to start with a ten French

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drainage catheter. Or if you're

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dealing with more viscous collections,

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like in the case of peripancreatitis,

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you might use a 14 or 16 French catheter.

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But then you need to dilate up to that, right?

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And so once you've dilated up, you're

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like, okay, the pump has been primed.

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So now we're ready to just melt that bad

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boy through the skin, the catheter into the

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collection, over the wire, nice little railroad.

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And then once we're in, the catheter takes the path

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of the wire, and then we pull the wire out.

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If we started with a nice blunt stiffener

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in the actual catheter, we then remove that.

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Here we see an image of the plastic

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stiffener that's typically in place,

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which is used usually for exchanges.

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And then the blunt metal stylet, which as you

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can see, the blunt tip is actually ending here.

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I kind of pulled it out a little bit

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just so you can see that the minute you

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pull it out, it kind of begins to form.

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And there's that string that Dr.

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Constance Cope sort of

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developed very, very ingeniously.

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So when this is pulled out, it naturally wants

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to form because of memory, a little pigtail.

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But then this little string, this

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little suture, allows you to, um, just kind

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of get it into position, so it kind of makes

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a nice little piggy pigtail loop.

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Okay?

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Gotta love the little piggy pigtail loop.

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So this is what it looks like.

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You know, in my hands, in your hands, it looks

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the same way, and once it's out, you know,

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you sort of get that nice pigtail to form.

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It's a nice little retention device.

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It forms with the shape of an abscess,

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which is typically round or spherical in nature.

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And then you have this sort of ring.

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In this case, this happens to be one of the

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manufacturers that makes this, and it

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has a little feature where you can kind

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of throw the string around this, and then, boom,

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just kind of lock it in place, cut the suture

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at this tip here, and then you're off to help

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the patient sort of move past this collection.

4:01

Alright, so what are the advantages

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of the Sellinger Technique, and

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let's talk about the disadvantages.

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Well, you know, this technique can facilitate

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the drainage of a large, multi-loculated collection.

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It allows you to get that wire in,

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and send your catheter wherever you want it to be,

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dependently, or non-dependently. Although, you

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might not want to go non-dependently, because fluid usually

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falls and collects in the dependent areas.

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So, it’s better to drain it from the bottom up,

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or from the dependent area to the non-dependent area.

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It allows for more control; you

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know, I’m an expeditious person when it

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comes to getting things done.

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I think that safety is first, and

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so for me, I tend to use the Sellinger technique

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because I feel

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it gives me a little bit more control.

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I believe that planning, staging, and

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ratcheting as I move forward with the

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procedure while locking in safe, controlled,

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and intentional steps is really the way I

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like to care for my patients.

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But we’re discussing advantages here for

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the purpose of your appraisal as well.

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So that you can determine

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which technique is best for you.

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For me, I feel like in cases

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where there are difficult-to-access

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collections, the Sellinger technique works pretty well.

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Some people think it’s a little time-consuming,

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you know, and it just depends on how pressed

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for time you are to move from this patient

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to the next. But it's completely up to you

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in terms of your discretion, what

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you think is time-consuming versus what’s not.

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One of the things people talk about is,

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sometimes there can be kinking

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that occurs with the guide wire. If you’re

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advancing a catheter with a stiffener through

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the wire, you might not get that catheter to end

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up in the abscess if you kink the wire.

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My response to that is perhaps,

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you should use a technique where you watch the

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catheter as it advances over the wire.

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What I teach our residents is that once you hit the trough or the

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crest of the wire, depending on where

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the wire’s going, you stop.

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Stop at the apex or the point

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of the trough or crest with the stiffener, and then

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begin to feed the catheter off the stiffener.

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Guide it onto the wire and into the collection,

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which helps to bypass the kinking risk.

Report

Faculty

Mikhail CSS Higgins, MD, MPH

Director, Radiology Medical Student Clerkships; Director, ESIR

Boston University Medical Center

Tags

Vascular Imaging

Vascular

Ultrasound

Interventional

Iatrogenic

Fluoroscopy

Angiography

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