Transjugular Liver Biopsy Technique

Updated: Jan 25, 2016
  • 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

Preparation

Obtain informed consent. Confirm that there is no contrast allergy and that the platelet count is higher than 50,000/μL. Patient should have nothing by mouth for 4-6 hours prior to the procedure.

Procedure

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.

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).

Prebiopsy right hepatic venography. 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).

7F sheath with metal guide after removing the Ampl 7F sheath with metal guide after removing the 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 2-3 cores to ensure that the tissue sample is adequate.

Biopsy needle advanced through the sheath after tu Biopsy needle advanced through the sheath after turning the guide anteriorly.
Angle the metal guide upward as shown, and then fi Angle the metal guide upward as shown, and then fire the 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

Potential complications of transjugular liver biopsy 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
  • Liver capsule puncture and abdominal pain [13]
  • Neck hematoma
  • Cardiac arrhythmias
  • Hemobilia [14]
  • Fistulation between the hepatic artery and the portal vein or biliary ducts [15]
  • Bile leakage [16]
  • Pseudoaneurysm [17]
  • 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. [18] No inadvertent injuries to the carotid artery were noted.

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