Biopsy and Drainage · IR Playbook

Tunneled Pleural Catheter Placement (-)

A tunneled indwelling pleural catheter provides long-term ambulatory drainage of a recurrent symptomatic pleural effusion, most commonly a malignant effusion. It is particularly useful with non-expandable lung or failed pleurodesis and is inserted under ultrasound guidance using a tunneled modified-Seldinger technique.

Indications

Recurrent symptomatic malignant pleural effusion selected for ambulatory drainage
Malignant pleural effusion with non-expandable lung
Recurrent effusion after failed chemical pleurodesis
Selected refractory recurrent non-malignant effusion despite optimal treatment of the underlying disease

Relative contraindications

Uncorrected coagulopathy or therapeutic anticoagulation
Very small or extensively multiloculated effusion unlikely to drain through one catheter
Inability to tolerate or maintain the catheter
Pleural infection with ongoing sepsis

Equipment

Ultrasound machine with sterile probe cover
Manufacturer-specific 15.5–16 Fr cuffed silicone IPC kit with introducer needle, J-tip guidewire, dilator, peel-away sheath, tunneller and one-way valve
1% lidocaine, syringes and infiltration needles
Scalpel, blunt dissection forceps, sutures and sterile dressing
Compatible vacuum drainage bottle or underwater-seal system

Procedure steps

Verify indication, patient identity, side, consent, antithrombotic plan and arrangements for home drainage.
Position the patient comfortably with the ipsilateral arm elevated. Use ultrasound to confirm fluid and mark the pleural entry and anterior-inferior exit sites.
Apply full sterile precautions. Infiltrate both skin sites, the complete subcutaneous tunnel, rib periosteum and parietal pleura with local anaesthetic.
Make two 1–2 cm incisions and create a 5–10 cm blunt subcutaneous tunnel. Pass the catheter through the tunnel without twisting and position the cuff within 1 cm of the exit-site incision.Pearl: Keeping the cuff near the exit site provides fixation while facilitating later removal.
Advance the introducer needle over the superior rib margin under ultrasound until pleural fluid is aspirated. Pass the guidewire freely into the pleural cavity and remove the needle.
Advance the dilator and peel-away sheath over the guidewire without excessive depth. Remove the wire and dilator, feed the fenestrated catheter through the sheath and peel the sheath away.
Ensure the catheter lies flat without kinking. Close the pleural-entry incision, secure the catheter as required and connect the drainage system; slow or stop drainage for chest pain, persistent cough, worsening breathlessness or instability.
Confirm free drainage, valve integrity, cuff position and haemostasis. Apply a sterile dressing, document the drainage plan and train the patient or caregiver before discharge.

Complications

Pneumothorax or visceral injury
Bleeding or haemothorax
Exit-site, tunnel or pleural infection
Catheter blockage, loculation or dislodgement
Catheter-tract metastasis

Exam pearls

Thoracic ultrasound is mandatory for selecting a safe pleural fluid access site
Pass the needle over the superior rib margin
Every fenestration must remain intrapleural
The cuff belongs within the subcutaneous tunnel, not outside the skin or inside the pleural cavity
Non-expandable lung is an indication for IPC rather than a contraindication

Viva questions

What is the principal indication for an IPC?: A recurrent symptomatic malignant pleural effusion requiring ambulatory drainage, particularly with non-expandable lung or failed pleurodesis.
Why is the catheter tunneled?: The tunnel and polyester cuff provide fixation and create a tissue barrier that reduces accidental dislodgement and migration of infection.
Where should the cuff be positioned?: Within the subcutaneous tunnel, approximately 1 cm from the exit-site incision.
When can an IPC be removed after spontaneous pleurodesis?: When drainage is below 50 mL on three consecutive occasions, symptoms have not recurred and imaging shows no substantial residual effusion.