We introduce a novel image-guided puncture technique using C-arm cone-beam CT (XperCT) with fluoroscopic overlay puncture application (XperGuide) performed on the Allura Clarity angiography system (Philips Medical) for drainage or biopsy, compared with CT-guided puncture method. The puncture line can be determined with XperGuide by setting the Target Point and the Entry Point on XperCT images. These two points are overlapped in the fluoroscopic image in a “Bull′s Eye” fashion in the Entry View. We can puncture the needle at the Bull′s Eye point in the Entry View, and confirm the puncture distance in the Progress View to reach the Target Point. The advantages and disadvantages compared with the CT-guided procedure should be recognized to use XperGuide system well.

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CT-guided puncture has become an indispensable technique at the time of various interventional radiology procedures such as percutaneous biopsy, ablation, drainage, and so on. To make a success of such procedures and avoid unnecessary complications, careful preparation and precise technique are required. In this article, some tips about the pre-procedural preparation and the puncture technique are introduced.

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MR-guidance is the least likely modality to be initially chosen for non-vascular interventional procedures. The procedures are more complex and cost is higher than Ultrasonography and Computed tomography. Additionally temporal resolution is lower than with the other two modalities when we use low magnetic field open type MR imagers. On the other hand, the MR image has some excellent characteristics such as high tissue contrast, the ability to acquire images in any arbitrary slice direction, ionizing radiation free imaging and real time thermometry. In this chapter, only nonvascular interventions (punctures, biopsy and percutaneous thermal ablations) are considered.
Low magnetic field open type MR imager is more favorable for MR-guided nonvascular interventional procedures because of high accessibility to patients, wide range of puncture direction and higher safety margin to metallic instruments. Recently, some reports of interventional procedures using higher magnetic field (1.5T and 3T) have been published.
Susceptibility artifact is a very important phenomenon. Thickness of the metallic needles and applicators are increased on MR images. This phenomenon depends on the volume of metallic needle or applicator, angle between magnetic field and needle and also parameters of scanning. We should understand the behavior of this artifact.
At the end of this chapter, a few clinical cases of MR-guided cryoablation will be presented.

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Ultrasound (US) -guided needle puncture is essential both for vascular and non-vascular intervention. We must be sensitive to technological advances of US such as fusion imaging with CT or MRI and needle enhancement processing. We need to understand tips of US-guided needle puncture. It is important to understand how to align the puncture needle precisely with the planned needle guideline. In addition, it is important to know how to correct the direction of the needle in case it deviates from the planned US guideline. By shifting the US probe and the needle just on the surface of the skin, the direction of the needle can be intentionally tilted and easily adjusted. In this manner, precise puncture can be easily achieved.
When PTBD of a non-dilated bile duct is necessary for patients with biliary complication after hepatobiliary surgery or liver transplantation, puncture along the longitudinal direction of the peripheral bile duct is useful. In cases with non-identified bile duct, parallel puncture or rendezvous technique using a microcatheter or a microguidewire inserted from another access is also helpful.

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Image guided puncture is one of the most fundamental techniques among many procedures that interventional radiologists should acquire. While the diversification of the techniques is accelerating, it usually depends on the skill and judgment of individual operators. Basically, the operators should know the characteristics of needles and acquire the skill and the sense of manipulating each needle with their own hands delicately. To that end, it is important that the attitude of continuing to refine their skills in daily practice, and as a result of that, it will be possible to achieve maximum results with minimal invasion. We report biliary intervention, radiofrequency ablation (RFA) and percutaneous drainage from the viewpoint of how to lead to success at sites considered to be difficult to puncture.

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Iatrogenic pseudoaneurysm (IPA) is a common but important complication following femoral vein puncture. We report three cases of IPA following femoral vein puncture during radiofrequency catheter ablation (RFCA). These patients underwent insertion of two 8- to 8.5-Fr sheaths in the right femoral vein and a 3-Fr sheath in the right femoral artery. In the first case, the right inguinal region appeared swollen the morning after RFCA. IPA in the deep external pudendal artery (DEPA) was revealed on contrast-enhanced computed tomography (CECT). In the second case, the right inguinal region was swollen on day 7 after RFCA. IPA in the DEPA was revealed on CECT. In the third case, the right inguinal region appeared swollen the morning after RFCA. CECT showed IPA in the medial circumflex femoral artery (MCFA). These IPAs were treated by transcatheter arterial embolization with microcoils. Because thrombolytic-anticoagulant therapy for atrial fibrillation increases vascular complication rates and because the superficial external pudendal artery, DEPA and MCFA run inside the femoral artery, femoral vein puncture procedure easily injures these arteries. Preoperative anatomical evaluation of femoral branches on CECT or Doppler ultrasonography may be able to reduce the risk of IPA.

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