Abdominal radiologists are often asked to perform difficult percutaneous chest, abdomen, and pelvis biopsies and drainages with imaging guidance. Many of these procedures involve small target lesions far from the skin surface, in close proximity to critical structures. Organ location is changeable due to respiration, peristalsis, and pulsation, further complicating the planning process. High-level three-dimensional spatial awareness is critical to mastery of complex image-guided procedures. A comprehensive grasp of anatomy and expected changes can be exploited in certain cases to target lesions within a solid organ or to avoid injury to sensitive structures during biopsy, drain placement, or thermal ablation. In this article, we will use illustrative cases to explore the use of anatomic knowledge and the ability to synthesize this three-dimensional data dynamically during planning and execution of difficult CT- and ultrasound-guided procedures. We will discuss unusual biopsy requests—such as bowel biopsies—and the benefits of using ultrasound guidance for certain procedures in the chest. Additionally, we will describe multiple special techniques, including out of standard plane angulation and endocavitary techniques, in order to maximize chances of success.
