Transjugular Liver Biopsy Technique

Updated: Feb 22, 2018
  • Author: Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR; Chief Editor: Justin A Siegal, MD  more...
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Technique

Biopsy of Liver via Transjugular Approach

Clean the skin on the neck with chlorhexidine or povidone-iodine solution. [12] Use ultrasound guidance to choose a point on the skin above the vein. Infiltrate 3-5 mL of local anesthetic.

Make a small (≤1 cm) horizontal skin incision. Using the 18-gauge puncture needle and ultrasound guidance, puncture the anterior wall of the vein and enter the vein (see the video below). Aspirate venous blood to ensure position.

Transjugular liver biopsy. Ultrasound-guided right internal jugular puncture.

Advance the 0.035-in. guide wire, and insert a 5-French sheath over the wire. Use a Cobra-2 catheter and Terumo hydrophilic wire to access the right hepatic vein. Then, perform venography to ensure that hepatic vein stenosis is absent and to assess parenchymal flow (see the image below).

Transjugular liver biopsy. Prebiopsy right hepatic Transjugular liver biopsy. Prebiopsy right hepatic venography.

Exchange the wire for an Amplatz wire, but do not advance too far out, so as to prevent inadvertent puncture of liver capsule. Remove the 5-French sheath, and insert the 7-French guide catheter with the inner metal guide and dilator. Once the system is 3-4 cm into the hepatic vein, remove the wire and inner dilator, leaving the metallic guide and sheath in the hepatic vein (see the image below).

Transjugular liver biopsy. 7-French sheath with me Transjugular liver biopsy. 7-French sheath with metal guide after removal of Amplatz wire.

Insert the 19-gauge biopsy needle. Once it is at the tip of the guide catheter, ask the patient to hold his or her breath, and turn the metallic guide upward so as to angle anteriorly in the vein (see the images below). Then, advance the needle out of the catheter and fire. Obtain at least two or three cores to ensure that the tissue sample is adequate.

Transjugular liver biopsy. Biopsy needle advanced Transjugular liver biopsy. Biopsy needle advanced through sheath after guide is turned anteriorly.
Transjugular liver biopsy. Angle metal guide upwar Transjugular liver biopsy. Angle metal guide upward as shown, and then fire gun.

Pearls

Avoid an anterior biopsy from the middle hepatic vein; use a posterior biopsy in these cases. If it is not possible to differentiate the right from the middle hepatic vein, use lateral imaging. To avoid capsule punctures in small livers, a 1-cm tip Amplatz wire is useful. [12]

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Complications

Transjugular liver biopsy has a good safety profile, and radiation exposure is low. [13] Potential complications include the following:

  • Bleeding - If this occurs, it is usually back into the hepatic vein, but if a hepatic arterial bleed occurs, the patient may need transfusion or even embolization; bone marrow transplant recipients may be at somewhat higher risk for postbiopsy hemorrhage [14]
  • Liver capsule puncture and abdominal pain [15]
  • Neck hematoma
  • Cardiac arrhythmias
  • Hemobilia [16]
  • Fistulation between the hepatic artery and the portal vein or biliary ducts [17]
  • Bile leakage [18]
  • Pseudoaneurysm [19]
  • Death (mortality, 0.1-0.5%)

The overall complication rate is in the range of 1.3-20.2%.

In a retrospective study of 341 consecutive patients who had undergone transjugular liver biopsy, Dohan et al found that the procedure was technically successful in 97.1%; that major complications (ie, intraperitoneal bleeding due to liver capsule perforation) occurred in only 0.6%; and that the minor complications of abdominal pain and supraventricular arrhythmia occurred in 10.3% and 4.4%, respectively. [20] No inadvertent injuries to the carotid artery were noted.

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