Trans-jugular liver biopsy

A trans-jugular 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

History

TJLB was first described by Charles Dotter in 1964³.

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 TJLB.

All attempts should be made to correct the coagulopathy. International normalised ratio of >1.7 and a platelet count of <40000 should be corrected before a patient is taken up for the procedure.

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

Procedure

Equipment required

• routine trolley pack
• TJLB set ( eg Cook TJLB set)
• puncture needle - 18G
• 9F sheath 11cm long
• guidewires (.035'') and stiff floppy tip glide wire
• catheters : 5F multipurpose / 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 anaesthesia may be required.

Technique

Under US guidance the internal jugular vein on the right side is punctured. A .035" guide wire inserted into the SVC and a 9F sheath is placed over the wire after adequate dilatation. Venous puncture can be done with micro-puncture set 21-22G 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 (multipurpose/ head hunter catheter with .035" wire serves this purpose). The SVC 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 right hepatic vein, a venogram is obtained to confirm the right hepatic vein position. 

The catheter is then exchanged with 7F 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

• haemorrhage : often the hemorrhage occurs into a hepatic vein; if the bleeding is arterial it requires angiography / embolisation. 
• liver capsular rupture + /- haemoperitoneum : close monitoring is required  post procedure (sufficient liver parenchyma has to be ensured anterior to RHV; if not left lobe or Middle hepatic vein to be selected)
• pneumothorax
• haemobilia
• fistulation between hepatic artery and portal vein or biliary ducts
• hepatic artery pseudoaneurysm

See also

• Liver and billiary interventional procedures