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PURPOSE: To objectively compare the echogenicity of several types of needles at clinically important angles of
insonation.
MATERIALS AND METHODS: Four commercial needles (Echotip, Mini-Stick, Echo-Coat, Surflo) and a prototype
dimpled needle were tested in a liver phantom at angles of insonation ranging from 90° to 15°. Photodensity
measurement determined echogenicity levels in arbitrary echogenicity units (EU).
RESULTS: At 90° angles of insonation all needles were easily seen (60 –76 EU) and echogenic levels were similar (P
ⴝ .264). All values decreased with angulation. From the 35° to 15° angles, the prototype and Echotip needles were
superior (P < .05). At 15° the values were 43 EU for the prototype needle, 40 EU for the Echotip needle, 9.0 EU for the
Echo-Coat needle, and 5.0 EU for the Surflo needle.
CONCLUSION: With angulation, all needles drop in echogenicity, with prototype dimpled and Echotip best main-
taining visibility at clinically important angles.
ADVANTAGES of ultrasound (US) dramatic improvements have come a non– echo-enhanced plastic-
guidance for needle placement include with needle modifications to increase sheathed needle (Surflo; Terumo, To-
real time observation of the needle, echogenicity. Some include dimpling kyo, Japan) were tested. The Echotip
lack of ionizing radiation, and rela- the needle tip, coatings, and texturing needle (Cook) had 54 dimples per low
tively low cost. In some cases, difficult with various methods. These modifi- power microscopic field and the pro-
anatomical access, shadowing by bone cations have improved echogenicity totype needle (Cook) had 70 dimples
or gas, and poor target visibility com- and provided more accuracy in local- per low power field (10⫻ magnifica-
promise its use. Among the limitations izing the needle tip and accessing tion; Fig 1). The Mini-Stick needle
to US guidance is poor needle visibil- small targets. The purpose of this (Meditech) had proprietary roughen-
ity at small angles of insonation, espe- study is to objectively compare nee- ing of the shaft near the tip. The Echo-
cially in echogenic organs (1–5). Al- dles with different echo enhancement Coat needle (STS Biopolymers) had a
though up to date US equipment and modifications with use of a quantita- thin film with small craters on the sur-
compound imaging can help, the most tive system. face that increased echogenicity along
its entire length (2,6). The Surflo nee-
dle (Terumo) was smooth plastic with
From the College of Medicine (K.N.), Department of MATERIALS AND METHODS a protruding metal tip.
Radiology (L.B.W., W.C.C.), and Department of Bio-
statistics (T.S.), University of Arkansas for Medical Devices A General Electric Logic 700 US
Sciences, 4301 West Markham Street, Little Rock, machine (GE Medical Systems,
Arkansas 72205. Received June 5, 2003; accepted July Commercial 21- or 22-gauge nee- Waukesha, WI) with a LA-39 trans-
21. Presented at SIR 2003 annual meeting. Address ducer and a linear 6 –13 MHz probe
dles with a dimpled distal shaft
correspondence to W.C.C.; E-mail: culpwilliamc@
uams.edu (Echotip; Cook, Bloomington, IN), a was used. All images were printed in
prototype needle with more dimples one batch with use of a Kodak 45150-
None of the authors have identified a potential con-
flict of interest. (Cook), an echogenic textured needle 3344 laser printer (Eastman Kodak,
(Mini-Stick; Meditech, Boston, MA), a Rochester, NY) with nine images per
© SIR, 2003
polymeric coated needle (Echo-Coat, sheet.
DOI: 10.1097/01.RVI.0000099527.29957.A6 STS Biopolymers, Henrietta, NY), and The phantom consisted of 14
1553
1554 • Needle Echogenicity at Varying Angles of Insonation December 2003 JVIR
Statistical Analysis
Statistical analysis included analy-
sis of variance and linear regression
techniques. Magnitude of echogenicity
was initially assessed with use of a
two-factor analysis of variance model
that included needle type and angle of
Figure 2. Graphic comparison of the prototype needle (Cook) shows that the echogenic insonation as main effects. The test for
modification on a small area near the tip greatly increases visibility compared with the interaction between these effects was
unmodified shaft of the same needle. In this phantom the echogenic area remains above found to be significant (P ⬍ .001),
the 40 EU level required for good visualization at all angles including 15°. The shaft which implies that inferences regard-
becomes poorly visualized at about the 60° angle and shows a negative value, less
ing needle type must be made sepa-
echogenicity than the phantom, at the 15° angle.
rately at each angle. Thus, one-way
analysis of variance models were per-
formed at each angle of insonation.
The Tukey method was used to adjust
ounces of commercial beef gravy Experimental Protocol for multiple comparisons made at
(Kroger Beef Gravy, Kroger, Cincin- each angle. To determine which nee-
nati, OH) mixed with 8 cups of water One needle of each type was placed dles exhibited the least change in
to match the echogenic appearance of in the phantom at standard depths echogenicity, linear regression models
fresh calf liver. A single mixture of and angles ranging from 15° to 90° were used to estimate slopes and to
phantom was used for all measure- relative to the US beam. Angles of in- compare them between each needle
ments. A magnetic stirrer was placed sonation were measured from the US type. Adjustments for multiple com-
in the phantom bowl and kept the screen as the needles were rotated on a parison were made so that the overall
medium in suspension during the pivot device in the phantom. The six type I error rate was no larger than the
trials. brightest images on visual inspection 0.05 level.
Volume 14 Number 12 Nichols et al • 1555
DISCUSSION
US guidance for invasive proce-
dures is a well-established technique
that continues to gain in popularity. In
most situations it is used with high
Figure 4. Longitudinal US images of the prototype needle (Cook). At the 75° angle, the success rates; however, needle visibil-
smooth shaft is adequately seen and the echogenic tip is clearly seen (a). At the 35° angle,
ity remains a limitation in many situ-
the smooth shaft is faint while the echogenic tip is still clearly seen (b).
ations. Good needle visibility is ex-
pected in tissues that are relatively
sonolucent and when angles of in-
sonation approach 90°. Needle visual-
RESULTS creased in all cases, but the magnitude ization is a problem with targets of
of this decrease varied with each nee- increased depth or tissue echogenicity
At 90° angles of insonation, all nee- dle. The sheathed needle, Surflo and when targets require small angles
dle types were easily seen and had (Terumo), demonstrated the steepest of insonation. Factors effecting needle
similar echogenic values ranging from slope (had the greatest drop in visibil- conspicuity include the characteristics
60.8 to 75.8 EU (Fig 3). At all angles of ity) across decreasing angles of in- of the tissue through which the needle
insonation less than 90°, the prototype sonation and had the lowest EU values is passing, the size of the needle, echo-
needle (Cook) had the highest average at every angle less than 75°. At angles genic factors of the needle, and the
echogenicity. Needle echogenicity de- less than 60°, the values for the Surflo angulation between the US beam and
creased as the angle of insonation de- needle (Terumo) and the smooth shaft the surface of the needle. These factors
1556 • Needle Echogenicity at Varying Angles of Insonation December 2003 JVIR
the prototype needle (Cook) rated as sualization of biopsy needles with ul- cally guided invasive procedures. AJR
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