Background
Transjugular liver biopsy was first performed in 1970 and is now an accepted method of liver biopsy when the percutaneous technique is contraindicated. [1, 2] Some clinicians have considered this technique to be inferior to the percutaneous technique on the grounds that it yields an inadequate sample. [3, 4, 5] This disadvantage has been overcome over the years by using 18-gauge or larger Tru-Cut biopsy needles and by obtaining more than one core. [6, 7]
Indications
Transjugular liver biopsy is indicated for patients with diffuse liver disease who need a biopsy and have one or more of the following [5, 8] :
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Massive ascites
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Liver abnormalities such as peliosis hepatitis
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In combination with transjugular intrahepatic portosystemic shunt (TIPS) or venography
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Any other contraindication for percutaneous biopsy
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Failed percutaneous biopsy
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Morbid obesity
Transjugular liver biopsy may be performed in children as well as in adults, but the tissue yield has been reported to be generally poorer than that of percutaneous biopsy in this population. [11] A study by Lal et al found transjugular liver biopsy to be well tolerated and feasible in 102 patients younger than 18 years, facilitating diagnosis in 64%; the procedure appeared to be particularly useful for helping to identify autoimmune liver diseases, drug-induced liver injury, and noncirrhotic portal fibrosis. [12]
Contraindications
No specific contraindications exist for transjugular liver biopsy, but attempts should be made to correct coagulation derangements before proceeding. A study by Sue et al found that transjugular liver biopsy is safe even in patients with severe coagulopathies and multiple biopsies. [13]
Lack of venous access is a limitation for this procedure. Evidence suggests that transjugular liver biopsy can be safely and effectively performed after TIPS or direct intrahepatic portocaval shunt (DIPS). [14]
This technique should not be used in assessing focal liver lesions.
Technical Considerations
Anatomy
Puncture of the right internal jugular vein (IJV) is preferred because the right-side approach offers a straighter route for the 7-French sheath and metal guide. Alternate sites, such as the left IJV and the inferior vena cava (IVC), have also been used. [15] The IJV lies anterior and lateral to the carotid artery. A low puncture increases the risk of pneumothorax, and a high puncture increases the risk of arterial puncture, in that the artery now lies posterior to the vein; thus, a puncture in the middle portion of the IJV is ideal. [16]
Entry into the right hepatic vein is recommended because sufficient liver tissue is available anteriorly, and the metal guide can easily be directed anteriorly. If the middle hepatic vein is entered, it is important to ensure that the guide is turned posteriorly.
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Transjugular liver biopsy. Ultrasound-guided right internal jugular puncture.
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Transjugular liver biopsy. Prebiopsy right hepatic venography.
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Transjugular liver biopsy. 7-French sheath with metal guide after removal of Amplatz wire.
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Transjugular liver biopsy. Biopsy needle advanced through sheath after guide is turned anteriorly.
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Transjugular liver biopsy. 7-French sheath (outer blue) with inner straight catheter (black).
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Transjugular liver biopsy. Biopsy needle.
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Transjugular liver biopsy. Sheath with metal stiffener. Note metal guide at proximal end.
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Transjugular liver biopsy. Angle metal guide upward as shown, and then fire gun.
