Transjugular Liver Biopsy

Transjugular liver biopsy was first performed in 1970 and is now an accepted method of liver biopsy when the percutaneous technique is contraindicated.[1, 2] Some clinicians have considered this technique to be inferior to the percutaneous technique on the grounds that it yields an inadequate sample.[3, 4, 5] This disadvantage has been overcome over the years by using 18-gauge or larger Tru-Cut biopsy needles and by obtaining more than one core.[6, 7]

Transjugular liver biopsy is indicated for patients with diffuse liver disease who need a biopsy and have one or more of the following[5, 8] :

• Deranged coagulation ^{[9, 10]}
• Massive ascites
• Liver abnormalities such as peliosis hepatitis
• In combination with transjugular intrahepatic portosystemic shunt (TIPS) or venography
• Any other contraindication for percutaneous biopsy
• Failed percutaneous biopsy
• Morbid obesity

Transjugular liver biopsy may be performed in children as well as in adults, but the tissue yield has been reported to be generally poorer than that of percutaneous biopsy in this population.[11]  A study by Lal et al found transjugular liver biopsy to be well tolerated and feasible in 102 patients younger than 18 years, facilitating diagnosis in 64%; the procedure appeared to be particularly useful for helping to identify autoimmune liver diseases, drug-induced liver injury, and noncirrhotic portal fibrosis.[12]

No specific contraindications exist for transjugular liver biopsy, but attempts should be made to correct coagulation derangements before proceeding. A study by Sue et al found that transjugular liver biopsy is safe even in patients with severe coagulopathies and multiple biopsies.[13]

Lack of venous access is a limitation for this procedure. Evidence suggests that transjugular liver biopsy can be safely and effectively performed after TIPS or direct intrahepatic portocaval shunt (DIPS).[14]

This technique should not be used in assessing focal liver lesions.

Anatomy

Puncture of the right internal jugular vein (IJV) is preferred because the right-side approach offers a straighter route for the 7-French sheath and metal guide. Alternate sites, such as the left IJV and the inferior vena cava (IVC), have also been used.[15]  The IJV lies anterior and lateral to the carotid artery. A low puncture increases the risk of pneumothorax, and a high puncture increases the risk of arterial puncture, in that the artery now lies posterior to the vein; thus, a puncture in the middle portion of the IJV is ideal.[16]

Entry into the right hepatic vein is recommended because sufficient liver tissue is available anteriorly, and the metal guide can easily be directed anteriorly. If the middle hepatic vein is entered, it is important to ensure that the guide is turned posteriorly.

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.

A commonly used biopsy kit is manufactured by Cook Medical (Bloomington, IN). The kit contains the following materials, which can be assembled if the kit is unavailable:

• Long (49 cm) sheath, 7 French (see the first image below)
• Angled metal sheath stiffener (see the second image below)
• Straight catheter, 5 French
• Cutting biopsy needle, 60 cm (see the third image below)
• Multipurpose catheter, 5 French
• Guide wire

Transjugular liver biopsy. 7-French sheath (outer blue) with inner straight catheter (black).

Transjugular liver biopsy. Sheath with metal stiffener. Note metal guide at proximal end.

Transjugular liver biopsy. Biopsy needle.

Other equipment needed includes the following:

• Ultrasound machine with linear-array probe
• Fluoroscopy
• Skin disinfectant (eg, chlorhexidine, povidone-iodine solution)
• Heparinized saline (1000 U heparin in 1000 mL of 0.9% NaCl)
• Basic angiography kit, including puncture needle
• Sheath, 5 French
• Cobra-2 catheter
• Hydrophilic-coated guide wire (eg, from Terumo, Somerset, NJ)
• 1-cm floppy-tip Amplatz guide wires

Anesthesia

In adults, local anesthesia (eg, lidocaine 1% 10 mL) is required for the jugular puncture site on the neck. (For more information, see Local Anesthetic Agents, Infiltrative Administration.) In children, general anesthesia is usually required for this procedure.

Positioning

Position the patient supine with the patient’s head turned away from the jugular puncture site.

Clean the skin on the neck with chlorhexidine or povidone-iodine solution.[17] Use ultrasonographic (US) 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 with US guidance, puncture the anterior wall of the vein, and enter the vein (see the video below). Aspirate venous blood to ensure position.

Advance the 0.035-in. guide wire, and insert a 5-French sheath over the wire. Use a Cobra-2 catheter and a 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 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 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 through sheath after guide is turned anteriorly.

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.[17]

Transjugular liver biopsy has a good safety profile, and radiation exposure is low.[18] 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 ^[19]
• Liver capsule puncture and abdominal pain ^[20]
• Neck hematoma
• Cardiac arrhythmias
• Pneumothorax
• Hemobilia ^[21]
• Fistulation between the hepatic artery and the portal vein or biliary ducts ^[22]
• Bile leakage ^[23]
• Pseudoaneurysm ^[24]
• 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.[25] No inadvertent injuries to the carotid artery were noted.

A retrospective review (N = 1467) using data from the New York Statewide Planning and Research Cooperative System assessed complication rates, mortality, and readmission rates in patients undergoing either percutaneous liver biopsy (n = 978) or transjugular liver biopsy (n = 489).[26] ​ The patients in the percutaneous group had a significantly higher rate of hematoma, whereas those in the transjugular group had a significantly higher rate of cardiac complications; these findings supported earlier work suggesting that transjugular liver biopsy may be safer than percutaneous liver biopsy in patients with hemostatic disorders or advanced liver disease.