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 Table of Contents  
HOW TO DO IT
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 73-75

How to do it: Transjugular liver biopsy


Division of Interventional Radiology, Department of Radiology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission20-Aug-2020
Date of Decision11-Jan-2021
Date of Acceptance23-Feb-2021
Date of Web Publication25-Apr-2021

Correspondence Address:
Dr. Udit Chauhan
Room No-13 Trauma Block, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_148_20

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How to cite this article:
Gupta P, Chauhan U, Tayal M, Sharma P. How to do it: Transjugular liver biopsy. J Med Evid 2021;2:73-5

How to cite this URL:
Gupta P, Chauhan U, Tayal M, Sharma P. How to do it: Transjugular liver biopsy. J Med Evid [serial online] 2021 [cited 2022 Aug 12];2:73-5. Available from: http://www.journaljme.org/text.asp?2021/2/1/73/314615


  Introduction Top
Liver biopsy was first described in 1884 by von Frerichs.[1] Transjugular liver biopsy (TJLB) was first described on dogs in an experimental model in 1964 by Dotter,[2] but it was performed for the first time clinically in humans by Hanafee and Weiner in 1967 following which it has found its way into routine clinical practice.[3] Over the years, liver biopsy has become the gold standard for chronic and acute liver disorder evaluation and helps in providing information regarding the diagnosis, progression of disease and response to the therapy, thereby helping the clinician in assessing liver disease severity and also histological diagnosis.[4],[5] TJLB is safe in cirrhotic patients even with deranged international normalised ratio (INR) values, with no need for coagulation correction, but in haematological patients, platelet/plasma supplementation may be needed.[6]
  Indications for Transjugular Liver Biopsy Top
Indications for TJLB are a result from contraindications to percutaneous liver biopsy.[7],[8],[9] These include:
  1. Gross ascites
  2. Deranged coagulation – a low platelet count <50,000 × 10[9]/L or prolonged prothrombin time (PT) or partial thromboplastin time (PTT) and INR is >1.5 (abnormal liver test in haematological patients)
  3. Other reasons, for example, extreme obesity, a small shrunken liver or peliosis hepatis
  4. Contraindication to percutaneous access (it is important to note that even mild biliary radicle dilatation is contraindicated)
  5. Failed percutaneous biopsy
  6. Coexisting need for transvenous hepatic manometry
  7. Severe alcoholic hepatitis
  8. Acute liver failure of unknown aetiology
  9. Non-cirrhotic portal hypertension.

  Contraindications for Transjugular Liver Biopsy Top
  1. Lack of appropriate venous access like bilateral internal jugular venous (IJV) thrombosis
  2. Hydatid cyst
  3. Central hepatic occlusion
  4. Biliary obstruction causing cholangitis
  5. Severe, uncorrectable coagulopathy: A low platelet count <50,000 × 109/L or prolonged PT or PTT and INR is >1.5
  6. Thrombosis of the hepatic veins (HVs)
  7. Absence of co-operation from the patient.[7],[10]

  Equipment Used Top
  • Angiography laboratory with ultrasound (USG) machine
  • TJLB set (LABS-100 set with Tru-Cut Quick-Core biopsy needle of Cook, Bloomington), 9F short sheath (11 cm, Glidesheath™ Hydrophilic Coated Introducer Sheath, Terumo, Somerset, New Jersey), 5F catheters (Cobra, Kumpe [KMP] multipurpose and Headhunter, Cook, Bloomington) and guidewires (0.035” stiff glidewire and guidewire, Cook, Bloomington).

  Patient Preparation Top
TJLB is an outpatient elective procedure and may be performed in an inpatient with fulminant liver failure on an emergency basis. USG abdomen should be performed before TJLB procedure for assessment of liver size, to identify any focal lesion and for the assessment of the HV. Before the procedure, fasting is required for 4–6 hrs to reduce any remote possibility of aspiration and in case patient requires mild sedation. Informed consent has to be obtained in concordance with the SIR guidelines. The possibility of contrast allergy should be evaluated in all the patients and standard guidelines of premedication should be used for those patients having moderate contrast reactions in accordance with the American College of Radiology Manual on Contrast Media.[11] As mentioned in indications, TJLB may be performed in patients with deranged coagulation parameters. However, correction of these parameters is highly recommended in these patients which is variably defined as per institution protocol.[5],[7],[12]
  Patient Position Top
  • Patient should be made comfortable and should lie down in the supine position
  • Transjugular access is preferred, but transfemoral access may be considered in patients with central venous occlusion.
[TAG:2]Procedure Steps of Transjugular Liver Biopsy[/TAG:2] Initial steps
  • Sterilely prepare and drape skin access site
  • The procedure should be done from the head end of the patient
  • The patency of the right jugular vein should be confirmed by USG
  • Administer 1% lidocaine for local anaesthesia intradermally and subcutaneously (10 mL) to prevent pain at the site of puncture
  • Obtain percutaneous venous access: Under USG guidance using an 18G metallic puncture needle or an 18G metal puncture needle with a plastic cannula, the right IJV (single wall) is punctured, by Seldinger's technique. Puncture is preferable done in axial plane
  • Right jugular vein is preferred over left due to relatively straight course
  • A 10-mL syringe filled with sterile saline is connected to the 18G metallic puncture needle to preventing air embolism. The right IJV puncture is confirmed by aspiration of blood into the syringe
  • Monitoring of the patient should be done throughout the procedure with blood pressure (BP), electrocardiography and SPO2 measurement.
Liver biopsy
  • A hydrophilic guidewire (0.035” J/straight tip) followed by a 5-Fr multipurpose catheter is introduced through the right IJV into the superior vena cava, the right (or left) atrium and the inferior vena cava under fluoroscopic control
  • The right HV (RHV) is cannulated using guidewire. This should be followed by advancement of 5-Fr catheter into the RHV
  • Position is confirmed with venography as RHV runs posteriorly when viewed laterally. HV anatomy should be demonstrated by venography and also to check the catheter position
  • Hydrophilic guidewire is removed followed by placement of 0.035” Amplatz guidewire in RHV. After this, the catheter is withdrawn 'over the wire'
  • TJLB stiffening cannula – 7F sheath is advanced over stiff 0.035” Amplatz guidewire
  • Exchange wire for biopsy needle via 7-Fr guide long sheath
  • Rotate 7-Fr guide sheath/cannula so the tip faces anteriorly (note – If for some reason middle HV is cannulated for biopsy, the tip should face to the right side)
  • Maintain gentle forward pressure on guide sheath
  • Advance biopsy cutting needle into hepatic parenchyma
  • Activate spring-firing mechanism of needle
  • Remove needle to obtain specimen
  • Reinsert biopsy needle to obtain additional samples
  • The biopsy needle is advanced across the HV wall and the tip of the biopsy needle should not be placed in the peripheral third of liver parenchyma to avoid capsule rupture (tip for adequate position – venography with pressure helps to outline liver and gives guidance for length of needle to be advanced into the parenchyma based on parenchymal blush and prevents capsular puncture) [Figure 1] and [Figure 2].
Figure 1: Diagrammatic representation displaying cannulation of the right hepatic vein with transjugular liver biopsy sheath and passage of biopsy needle across the right hepatic vein into the liver parenchyma

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Figure 2: Digital subtraction angiography image (a) displaying cannulation of the right hepatic vein with KMP catheter along with venogram to delineate right hepatic vein anatomy. Also note the parenchymal blush revealing approximate liver outlines. Fluoroscopic image (b) showing placement of biopsy needle into the parenchyma across the right hepatic vein lumen (arrow in b). Fluoroscopic image (c) showing passage of biopsy needle further into the liver parenchyma for sampling (arrow in c). Digital subtraction angiography image (d) Venogram revealing normal appearance of parenchyma after biopsy

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Post-biopsy
  • Venogram is performed following biopsy
  • Evaluate for capsular perforation seen as free intraperitoneal or subcapsular contrast opacification/collection
  • Consider gelfoam embolisation if above positive or in high-risk patients
  • Remove cannula by pulling out
  • Manual compression is done at the puncture site to obtained haemostasis
  • Dressing applied.
Findings and reporting
  • Digital subtraction angiography-venography findings
  • Hepatic venous pressure measurements (if done)
  • Location and number of core biopsies obtained
  • Any immediate/periprocedural complications.
Post-procedure care
  • The patient should be placed in sitting/semi-recumbent position for 6 h post-procedure
  • The vital monitoring should be done (pulse and BP) – 15 min for 1 h and then every 30 min for the next 1 h followed by hourly for 4 h or until discharged
  • Changes in abdominal girth can be monitored in cases of suspected haemorrhage.
[TAG:2]Complications[/TAG:2] According to the SIR criteria, complications should be categorised as major or minor complications.[13] The most feared complications are intraperitoneal haemorrhage and death. Immediate periprocedural complications may include abdominal pain, supraventricular arrhythmia and capsular perforation without intraperitoneal haemorrhage. Delayed complications may be venous thrombosis/stenosis at access site and fistula between HV and artery or bile duct. [TAG:2]Summary[/TAG:2] TJLB is a simple procedure to obtain liver biopsies alongside hepatic manometry and has become an important step in reaching diagnosis and management of diffuse liver parenchymal diseases in appropriate setup. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

 
  References Top

1.
Colapinto RF. Transjugular biopsy of the liver. Clin Gastroenterol. 1985;14:451–67.  Back to cited text no. 1
    
2.
Dotter CT. Catheter biopsy. Experimental technic for transvenous liver biopsy. Radiology 1964;82:312-4.  Back to cited text no. 2
    
3.
Hanafee W, Weiner M. Transjugular percutaneous cholangiography. Radiology 1967;88:35-9.  Back to cited text no. 3
    
4.
Cholongitas E, Senzolo M, Standish R, Marelli L, Quaglia A, Patch D, et al. A systematic review of the quality of liver biopsy specimens. Am J Clin Pathol 2006;125:710-21.  Back to cited text no. 4
    
5.
Behrens G, Ferral H. Transjugular liver biopsy. Semin Intervent Radiol 2012;29:111-7.  Back to cited text no. 5
    
6.
Senzolo M, Burra P, Cholongitas E, Lodato F, Marelli L, Manousou P, et al. The transjugular route: The key hole to the liver world. Dig Liver Dis 2007;39:105-16.  Back to cited text no. 6
    
7.
Dohan A, Guerrache Y, Boudiaf M, Gavini JP, Kaci R, Soyer P. Transjugular liver biopsy: Indications, technique and results. Diagn Interv Imaging 2014;95:11-5.  Back to cited text no. 7
    
8.
Keshava S, Mammen T, Surendrababu NR, Moses V. Transjugular liver biopsy: What to do and what not to do. Indian J Radiol Imaging 2008;18:245-8.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Procopet B, Annalisa B. Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterol Rep (Oxf) 2017;5:79-89.  Back to cited text no. 9
    
10.
Nousbaum JB, Cadranel JF, Bonnemaison G, Bourlière M, Chiche L, Chor H, et al. Clinical practice guidelines on the use of liver biopsy. Gastroenterol Clin Biol 2002;26:848-78.  Back to cited text no. 10
    
11.
American college of Radiology.(2021).ACR Manual of contrast media 2021.https://www.acr.org/-/media/ACR/files/clinical-resources/contrast_media.pdf.  Back to cited text no. 11
    
12.
Chicago PA, Patterson R, Radin RC. Two pretreatment regimens for high-risk patients receiving radiographic contrast media. J Allergy Clin Immunol 1984;74:540-3.  Back to cited text no. 12
    
13.
Dohan A, Guerrache Y, Dautry R, Boudiaf M, Ledref O, Sirol M, et al. Major complications due to transjugular liver biopsy: Incidence, management and outcome. Diagn Interv Imaging 2015;96:571-7.  Back to cited text no. 13
    


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