HOW TO DO IT

Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 73-75

How to do it: Transjugular liver biopsy

Priyanka Gupta, Udit Chauhan, Mohit Tayal, Pankaj Sharma
Division of Interventional Radiology, Department of Radiology, AIIMS, Rishikesh, Uttarakhand, India

Correspondence Address:
Dr. Udit Chauhan
Room No-13 Trauma Block, AIIMS, Rishikesh, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_148_20

Introduction

Indications for Transjugular Liver Biopsy

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

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

• 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

Patient Position

• 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.

• 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.

• 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 Click here to view

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 Click here to view

• 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.

• Digital subtraction angiography-venography findings
• Hepatic venous pressure measurements (if done)
• Location and number of core biopsies obtained
• Any immediate/periprocedural complications.

• 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.

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