Changes in Ultrasonographic Echogenicity and

Visibility of Needles with Changes in Angles of

Insonation
Kremer Nichols, BS, Lonnie B. Wright, MD, Trey Spencer, MS, and William C. Culp, MD

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.

J Vasc Interv Radiol 2003; 14:1553–1557

Abbreviation: EU ⫽ echogenicity units

ADVANTAGES of ultrasound (US)
guidance for needle placement include
real time observation of the needle,
lack of ionizing radiation, and rela-
tively low cost. In some cases, difficult
anatomical access, shadowing by bone
or gas, and poor target visibility com-
promise its use. Among the limitations
to US guidance is poor needle visibil-
ity at small angles of insonation, espe-
cially in echogenic organs (1–5). Al-
though up to date US equipment and
compound imaging can help, the most
From the College of Medicine (K.N.), Department of
Radiology (L.B.W., W.C.C.), and Department of Bio-
statistics (T.S.), University of Arkansas for Medical
Sciences, 4301 West Markham Street, Little Rock,
Arkansas 72205. Received June 5, 2003; accepted July
21. Presented at SIR 2003 annual meeting. Address
correspondence to W.C.C.; E-mail: culpwilliamc@
uams.edu
None of the authors have identified a potential con-
flict of interest.
© SIR, 2003
DOI: 10.1097/01.RVI.0000099527.29957.A6
dramatic improvements have come
with needle modifications to increase
echogenicity. Some include dimpling
the needle tip, coatings, and texturing
with various methods. These modifi-
cations have improved echogenicity
and provided more accuracy in local-
izing the needle tip and accessing
small targets. The purpose of this
study is to objectively compare nee-
dles with different echo enhancement
modifications with use of a quantita-
tive system.
MATERIALS AND METHODS
Devices
Commercial 21- or 22-gauge nee-
dles with a dimpled distal shaft
(Echotip; Cook, Bloomington, IN), a
prototype needle with more dimples
(Cook), an echogenic textured needle
(Mini-Stick; Meditech, Boston, MA), a
polymeric coated needle (Echo-Coat,
STS Biopolymers, Henrietta, NY), and
a non– echo-enhanced plastic-
sheathed needle (Surflo; Terumo, To-
kyo, Japan) were tested. The Echotip
needle (Cook) had 54 dimples per low
power microscopic field and the pro-
totype needle (Cook) had 70 dimples
per low power field (10⫻ magnifica-
tion; Fig 1). The Mini-Stick needle
(Meditech) had proprietary roughen-
ing of the shaft near the tip. The Echo-
Coat needle (STS Biopolymers) had a
thin film with small craters on the sur-
face that increased echogenicity along
its entire length (2,6). The Surflo nee-
dle (Terumo) was smooth plastic with
a protruding metal tip.
A General Electric Logic 700 US
machine (GE Medical Systems,
Waukesha, WI) with a LA-39 trans-
ducer and a linear 6 –13 MHz probe
was used. All images were printed in
one batch with use of a Kodak 45150-
3344 laser printer (Eastman Kodak,
Rochester, NY) with nine images per
sheet.
The phantom consisted of 14

1553
1554 • Needle Echogenicity at Varying Angles of Insonation December 2003 JVIR

were captured at each angle. Images at

seven different angles yielded 42 mea-
sured images for each needle and 210
images in total. All needles were tested
on the same day, and the US settings
and photographic settings remained
constant throughout these trials.
Printed images were scanned onto
a picture archiving and communica-
tions system (PACS). Photodensity
units were assigned to various areas of
interest for the needle and the back-
ground area with use of Adobe Pho-
toshop 5.0 (Adobe Systems, San Jose,
Figure 1. Microscopic views (original magnification 40⫻) of prototype (Cook), Echo- CA). Optical densities of selected
Coat (STS Biopolymers), and Mini-Stick (Meditech) needles show distinct appearances. groups of pixels were measured
Note the large individual dimples of prototype needle (top) and the transition (arrow) to
within areas of interest including the
smooth shaft that still shows some microscopic texture. The Echo-Coat needle (STS
Biopolymers) coating (middle) has smaller craters that are effective, and shows a flaw needle tip, needle shaft, and adjacent
where the coating was removed by gentle scraping (arrowheads). The Mini-Stick needle background. On the Echotip (Cook)
(Meditech; bottom) has a rough texture on a very small scale that proves less effective at and prototype (Cook) needles, the
small angles of insonation. smooth shaft was measured in addi-
tion to the echogenic tip (Fig 2). The
areas of interest measured ranged
from 30 to 100 pixels for the needle
areas and greater than 1000 pixels for
the adjacent background. The adjacent
background value was subtracted
from the needle value to produce an
echogenicity value in echogenic units
(EU) for each target.

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

values for all needles were less than

7.3 EU. The smooth shaft of Echotip
(Cook) and prototype (Cook) needles
actually dropped below zero EU indi-
cating less echogenicity than this
phantom at low angles of insonation,
Fig 2. At angles down to 45°, the
Echotip (Cook), prototype (Cook), and
Echo-Coat (STS Biopolymers) needles
are similar in visibility (Figs 4 and 5)
and echogenicity (EU ⱖ 37.2 for all
three needles), but at the 25° angle, the
coated needle drops to 22.0 EU. Be-
tween the 35° and 25° angles, proto-
type (Cook) and Echotip (Cook) nee-
dles are almost stable and are superior
to all others (63.0 – 66.0 EU and 45.3–
Figure 3. Echogenicity graphs show that all needles (ETP ⫽ prototype needle, ET ⫽ 44.7 EU, respectively; P ⬍ .001). At the
Echotip, EC ⫽ Echo-coat, MS ⫽ Mini-Stick, TS ⫽ Surflo) are well seen and similar at very 15° angle, the prototype (Cook) and
large angles of insonation. A wide spectrum of echogenic levels is seen at the small angles Echotip (Cook) needles were better
often required in clinical situations. There the quality of the echogenic modification is of than all other needles (42.8 EU and
primary importance and only the prototype (Cook) and Echotip (Cook) needles remain 39.5 EU, respectively; P ⬍ .05; range of
above the 40 EU level required for good visualization at small angles of insonation.
remaining needles 5.0 – 8.8 EU) and
similar to each other.
Multiple comparisons analysis
found that the prototype (Cook) and
Echotip (Cook) needles had the shal-
lowest average slopes (0.26 slope, SE
⫽ 0.07 and 0.30 slope, SE ⫽ 0.06, re-
spectively; P ⬍ .03) and were each sig-
nificantly different from the remaining
needle types. The Echo-Coat needle
(STS Biopolymers) showed an inter-
mediate slope (0.65 slope, SE 0.08) dif-
ferent from the steep slopes of the
Mini-Stick (Meditech) and Surflo
(Terumo) needles (0.79 slope, SE 0.06
and 0.98 slope, SE 0.10, respectively; P
⬍ .05).

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
Figure 5. Longitudinal US images of the Echo-Coat needle (STS Biopolymers). The
coated shaft is easily seen at a moderate angle of 75° (a), but fades at 35° (b). The coating
allows good visualization of the entire shaft, an asset in some situations.
are in addition to the usual US factors
governing imaging, which are innate
to the machine and operator.
Many techniques have been used to
enhance echogenic properties of nee-
dles and improve guidance (1,6 –10).
The addition of echogenic features to a
needle has proved its worth when the
small angles of insonation compro-
mise visibility (1– 4). Many US biopsy
devices use angles of insonation of 15°
to 30° where needle tip visibility is
marginal. Free hand techniques may
also result in small angles of in-
sonation because of the anatomical re-
quirements of a particular target. In
this situation, the addition of an echo-
genic tip to the needle may be of crit-
ical importance.
The multiple factors involved make
commercially available needles diffi-
cult to compare in an objective man-
ner. Most reports use subjective grad-
ing of observers for comparison and
some companies make claims of good
visibility at small angles of insonation
on this basis. A standard phantom has
not yet appeared, and various materi-
als including commercial phantoms,
wet sponge, gelatin, and liquid have
been promoted by investigators. Ob-
jective measurement has been occa-
sionally used (2,4) but an accepted
standard technique for measuring
echogenicity has not yet been adopted.
Because of the great variability in
phantoms and equipment it seems
that a specific standard should not be
adopted at the present time. However,
arbitrary echogenicity or photodensity
measurements can be objectively mea-
sured and are the basis of this study.
After trying several commercially
available phantoms and grocery prod-
ucts, gelatins were discarded for this
project because contact of the needle
and transducer would often result in
spurts of echogenic air along the nee-
dle surface. This badly compromised
the echogenic measurements along the
needle. Turkey breast was not selected
because it is not homogeneous enough
for EU measurements and it is difficult
to change angles without introducing
air along the needle. A liquid phantom
was needed and several were tried
(11,12). A commercial gravy prepara-
tion was chosen that could be easily
diluted with water to match the echo-
genic texture of fresh calf liver, though
it lacked the structural features of the
organ. With this system, rapid mea-
surements were obtained at multiple
angles with no extraneous air bubbles
along the needles.
Objective EU values were calcu-
lated by subtracting an area of back-
ground phantom photograph density
from needle photograph density val-
ues. Echogenic units used here remain
December 2003 JVIR
an arbitrary measure related to the use
of this phantom, US machine, photog-
raphy, and computer program. Yet,
the use of Adobe Photoshop (Adobe
Systems) for measuring photograph
density units makes this a widely
available technique. These values are
different from that devised by Culp et
al (2) and yet the use of common nee-
dle types results in a conversion factor
of 11X to relate the current study val-
ues to the earlier values based on a
RadWorks system (Applicare Medical
Imaging B.V., Zeist, The Netherlands).
Four favorite needles in common
use by the authors were selected along
with a prototype extra dimpled nee-
dle. All of these needles showed good
conspicuity at large angles of in-
sonation. This included the entirely
smooth needle shafts and plastic can-
nula needles. This situation corre-
sponds to some clinical situations,
most notably peripherally inserted
central catheter placement in infants
and children where the smooth plastic
cannula is commonly used with great
success. However, as the angle of in-
sonation decreased, echogenic needles
became much more advantageous.
This corresponds to many biopsy sit-
uations and venous access in large pa-
tients or deep sites (1,13,14).
Although some echogenic needles
showed very little additional advan-
tage at small angles of insonation, oth-
ers were quite helpful. The Echo-Coat
needle (STS Biopolymers) was clearly
superior to Mini-Stick (Meditech), Sur-
flo (Terumo), and the untextured
smooth shaft of Echotip (Cook) and
prototype (Cook) needles. Although
most needles tested here have echo-
enhancement modifications that are
limited to the distal end of the needle,
the entirely coated needle, Echo-Coat
(STS Biopolymers), is visible at most
angles of insonation. This can be a
helpful feature; however, its echoge-
nicity dropped below the values of the
dimpled needles at the 35° angle and
further degraded as angulation pro-
gressed (Fig 5). At the 35° and 25°
angles, the prototype needle (Cook)
was clearly superior to all other nee-
dles, but it too dropped off at the 15°
angle. The prototype (Cook) and
Echotip (Cook) needles remained
clearly better than all others down to
the 15° angle where Echotip needle
(Cook) dropped out of the “good” cat-
egory into “adequate” leaving only
Volume 14 Number 12
the prototype needle (Cook) rated as
“good.” These categories converted
from Culp et al (2) correspond to
greater than 27 EU for “adequate” and
greater than 40 EU for “good” in the
current system.
All needles tested showed good
echogenicity at large angles of in-
sonation; however, as angulation de-
creased several needles became very
inconspicuous with only three remain-
ing useful down to the 45° angle. Be-
low this level the dimpled needles, es-
pecially the prototype dimpled needle,
are the clear choice for maximum
echogenicity.
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