Liver biopsy (transjugular)

Liver biopsy

(transjugular) • Transjugular liver biopsy - Ganzer Fall bei Radiopaedia

Desai P, Transjugular liver biopsy. Case study, Radiopaedia.org (Accessed on 06 Jan 2023) https://doi.org/10.53347/rID-10799 • CC by-nc-sa 3.0 (modified)

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Transjugular liver biopsy (TJLB) is an alternative to a percutaneous liver biopsy in patients with diffuse liver disease, coagulopathy and ascites.

It is sometimes done in combination with a transjugular intrahepatic portosystemic shunt (TIPSS) or venography.

Indications

massive ascites
coagulopathy
hepatic peliosis
morbid obesity
failed percutaneous liver biopsy or in a patient with a contraindication to percutaneous biopsy

Contraindications

There are no real contraindications for a transjugular liver biopsy.

All attempts should be made to correct the coagulopathy. International normalized ratio of >1.7 and a platelet count of <40 should be corrected before a patient is taken up for the procedure.

A transjugular liver biopsy should not be aimed at obtaining a biopsy for a focal liver lesion.

Procedure

Equipment required

routine trolley pack
TJLB set, e.g. Cook TJLB set
puncture needle: 18 G
9 F sheath 11 cm long
guidewires (.035'') and stiff floppy tip glide wire
catheters: 5 F multi purpose/headhunter/Cobra 2

Patient positioning

A patient is positioned supine in an angiography suite with an ultrasound machine available to help guide the internal jugular vein puncture. The procedure is usually done under local anesthesia however in uncooperative patients and in pediatric age group general anesthesia may be required.

Technique

Under ultrasound guidance the internal jugular vein on the right side is punctured. A .035" guide wire inserted into the superior vena cava and a 9 F sheath is placed over the wire after adequate dilatation. Venous puncture can be done with a micropuncture set 21-22 G in children and in patients with deranged coagulation parameters. A puncture too low carries a risk of a pneumothorax. Inadvertent carotid punctures should be avoided. Connecting the needle to a syringe containing saline helps identify venous entry. Then a combination of guidewire and a catheter is used to gain entry into the right hepatic vein (multi purpose/ head hunter catheter with .035" wire serves this purpose). The superior vena cava and the right atrium needs to be negotiated with the wire and catheter. Too much coiling of wire in the right atrium may give rise to arrhythmia hence continuous monitoring of pulse, ECG rhythm is mandatory during the procedure. Usually, the IVC can be traversed by asking the patient to be in deep inspiration. After gaining access to the right hepatic vein, a venogram is obtained to confirm the right hepatic vein position.

The catheter is then exchanged with 7 F TJLB sheath gently over a stiff wire. Once the tip of the sheath is in the mid RHV, trucut TJLB biopsy needle is inserted and 2-3 cores of liver tissue obtained after entering the liver parenchyma through the hepatic vein (this is done by anterior rotation of the TJLB sheath before obtaining biopsy specimen).

Post biopsy the patient has to be kept in semi-recumbent position. Puncture site hemostasis has to be ensured.

Complications

hemorrhage: often the hemorrhage occurs into a hepatic vein; if the bleeding is arterial it requires angiography/embolization.
liver capsular rupture +/- hemoperitoneum: close monitoring is required post procedure (sufficient liver parenchyma has to be ensured anterior to the right hepatic vein; if not, then left lobe or middle hepatic vein to be selected)
pneumothorax
hemobilia
fistulation between hepatic artery and portal vein or biliary ducts
hepatic artery pseudoaneurysm

History and etymology

Charles Dotter first described the transjugular liver biopsy in 1964 .