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Jeffrey I. Mondschein, MD

Hepatobiliary and portal Venous
interVentions

1. What are the indications for percutaneous transhepatic biliary drainage?

Percutaneous biliary drainage is indicated for the treatment of cholangitis or pruritus related to hyperbilirubinemia in

the setting of benign or malignant obstructive biliary disease. Biliary drainage may also be performed in the setting of

a traumatic bile leak to help divert bile and promote healing of the injured duct. Generally, percutaneous drainage is

indicated only if access of the ducts via endoscopic retrograde cholangiopancreatography is impossible.

2. List the causes of benign and malignant biliary obstruction.

•

Common benign causes include bile duct calculi (

Fig. 34-1

), benign strictures, pancreatitis, and sclerosing cholangitis

(

Fig. 34-2

).

•

Less common benign causes include Caroli disease, Mirizzi syndrome, and parasites.

•

Common malignant causes include pancreatic cancer (

Fig. 34-3

), metastatic disease, and cholangiocarcinoma.

•

Less common malignant causes include gallbladder carcinoma and ampullary tumors.

3. What is the most commonly encountered biliary ductal anatomy?

The main left bile duct is formed by the union of two horizontally oriented superior and inferior segmental ducts. Right lobe

ductal anatomy is more complex and variable. The posterior-inferior and posterior-superior portions of the right hepatic lobe

are drained by the right posterior ducts (also known as the right dorsal caudal ducts). The anterior-inferior and anterior-

superior portions of the right hepatic lobe are drained by the right anterior ducts (also known as the right ventral cranial

ducts). The main right hepatic duct is formed by the union

of the right posterior and anterior ducts. The confluence of

right and left ducts forms the common hepatic duct, which

is joined by the cystic duct (from the gallbladder) to form

the common bile duct. The most common biliary ductal

anatomy (approximately 60% of the population) consists of

a right posterior segment duct that joins the right anterior

segment duct to form the main right duct (

Fig. 34-4

).

4. Describe the basic steps required

to perform diagnostic percutaneous

transhepatic cholangiography.

Under fluoroscopic guidance, a 21G or 22G needle is

passed into the liver through an inferior intercostal

or subcostal space at the level of the right mid-

axillary line. It is important to verify that the needle

does not pass through the pleural space. The needle

is withdrawn during injection of contrast agent in

an effort to opacify a bile duct that may have been

traversed as a result of the needle pass. When a

bile duct is identified, injection of contrast agent

is continued, and the biliary tree is opacified. A

diagnostic cholangiogram is performed with spot

images obtained in anteroposterior and multiple

bilateral oblique projections.

Key Points: Biliary Drainage

1. An obstructed, infected biliary system constitutes a medical emergency.

2. Complications from percutaneous biliary drainage can be life-threatening. An endoscopic approach is preferred

when possible.

Figure 34-1.

Percutaneous transhepatic cholangiogram performed to

relieve biliary obstruction shows multiple common bile duct stones, seen

as filling defects among the injected intrabiliary contrast material.

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Hepatobiliary and portal Venous interVentions

5. Describe the basic steps required to perform percutaneous transhepatic biliary

drainage.

If indicated by the diagnostic percutaneous transhepatic cholangiogram and clinical symptoms, a wire can be placed

via the accessing needle into the biliary tree, followed by tract dilation and biliary drainage catheter placement. This is

called the “one-stick” method. If the initial puncture was directed into a central duct, a “two-stick” technique may be

used. Central duct punctures are not ideal because the risk of injuring a major hepatic vessel is significant. A second

needle may be placed into an appropriate duct that subsequently is dilated and used for access. The ideal access site is

an opacified peripheral duct that can be easily accessed under fluoroscopic guidance. Aside from a peripheral location,

the duct’s path should course through an angle that is gentle enough to allow a catheter to be advanced into the small

bowel without extreme angulation. After the second access is obtained, the first needle can be removed. If left-sided

biliary drainage is being performed, the needle is passed into the liver from a left subxiphoid approach.

A

B

RASD

RPSD

LHD

Figure 34-4.

A, The most common biliary ductal anatomy consists of a right posterior segment duct (RPSD) that joins the right anterior

segment duct (RASD) to form the main right duct. LHD = left hepatic duct.

B, Variant insertions of the RPSD.

Figure 34-2.

Percutaneous transhepatic cholangiogram shows

“beading” of intrahepatic biliary ducts, with segments of duct dilation

proximal to regions of duct stricture. This stricture-dilation pattern is

common in sclerosing cholangitis.

Figure 34-3.

Percutaneous transhepatic cholangiogram shows

intrahepatic biliary dilation secondary to malignant stricture of the

common bile duct. This condition was due to carcinoma of the

pancreatic head.

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6. What is the difference between an external biliary drainage catheter and an internal/

external biliary drainage catheter?

External drains end internally within the bile ducts above the site of obstruction. The obstructed biliary tree is

decompressed by draining the bile externally into a drainage bag. Internal/external drains cross the site of obstruction

and end within the small bowel. Bile may drain internally from the biliary tree through side-holes in the catheter into the

small bowel, and the catheter may be capped externally. Internal/external drainage catheters are placed whenever it is

possible to cross the site of obstruction because this type of drainage is more physiologic. Internal drainage prevents

loss of bile salts and electrolytes and allows the bile to aid in fat metabolism within the bowel. It is important to monitor

the volume status and electrolytes of patients draining bile externally. These patients can lose a large volume of fluids

rich in electrolytes.

7. When should an internal/external drain be capped? When should this drain be

uncapped?

After a de novo biliary drainage, catheters are almost always attached to a bag for gravity drainage for a specified time.

External drainage helps to decompress the biliary system. A pressurized system may promote bacterial translocation

into the hepatic vasculature, resulting in sepsis. Obstructed systems are likely to be pressurized, and this is exacerbated

by the contrast agent injected into the ducts during the procedure. Pruritus often resolves faster if drainage is

maximized. In the setting of a malignant obstruction, administration of chemotherapeutic agents may be delayed if

the serum bilirubin level is excessively elevated. In certain situations, internal and external drainage may accelerate

normalization of the serum bilirubin level and allow for the subsequent administration of chemotherapeutic agents.

Patients with drains placed for external drainage can lose a significant amount of fluids and electrolytes. Tubes are

commonly capped when possible to allow more physiologic drainage of bile. Usually this occurs when concerns over

infection have subsided, and pruritus has resolved. If chemotherapy is planned, tube capping may be delayed until the

serum bilirubin level is within an acceptable range.

After a tube has been capped, it should be uncapped because of infectious concerns (fever, bacteremia, sepsis, elevated

white blood count), leakage of bile around the catheter, pain, and increasing bilirubin or other liver enzyme levels. After

the tube is uncapped, additional tests may be indicated, such as a tube check to determine whether the tube is clogged

or malpositioned.

8. A patient begins to leak bile around an indwelling biliary drain. Why does this

happen? What can be done?

Biliary drains require considerable maintenance after they are placed, and the maintenance often adversely affects

the quality of life of patients. Tubes leak for various reasons. Standard biliary tubes consist of a catheter with

side-holes and a distal locking loop. For the tube to work properly, the side-holes must be patent and properly

positioned. The key to proper positioning is the proper location of the most peripheral side-hole. This hole should

be located just inside the biliary duct where access was obtained. If the most peripheral side-hole of the catheter

is malpositioned, leakage also occurs. Migration or malposition of the tube so that the hole is outside of the duct

and in the parenchymal tract results in bile leaking back along the catheter onto the skin. If the hole is too far in,

the bile duct peripheral to the catheter may become obstructed and leak along the course of the catheter. A careful

cholangiogram and meticulous tube placement solve these problems. Another common cause of leakage is clogging

of the side-holes of the catheter with viscous bile. This situation can be managed with catheter exchange with

consideration given to upsizing the tube if the complication occurs frequently.

9. What are the potential complications associated with percutaneous transhepatic

biliary drainage?

Even in the absence of clinical signs of cholangitis, bile in an obstructed system is often colonized with bacteria. Biliary

sepsis, a potentially lethal complication, may occur during or after a cholangiogram or biliary drainage. Antibiotics should

be given during a biliary drainage, and patients should be monitored closely for signs of sepsis. Injury to blood vessels

adjacent to the bile ducts within the hepatic parenchyma may be associated with pseudoaneurysms, hemorrhage, and

hemobilia. Bile leakage and bile peritonitis, and complications related to intraprocedural sedation (respiratory failure and

aspiration) may occur. Pneumothorax and reactive or bilious pleural effusions are uncommon complications if care is

taken during initial needle placement.

10. After an initial drainage procedure, what additional management measures may be

performed to treat benign biliary obstruction?

Biliary drainage provides access to the bile ducts that may allow for retrieval of biliary calculi. Balloon dilation of benign

ductal strictures with gradual upsizing of drainage catheter diameter may allow for remodeling of the bile duct with

eventual relief of obstruction and removal of the drainage catheter. This therapy, when successful, usually takes several

months. If unsuccessful, surgical intervention may still be possible, or catheters may be left in place for the long-term.

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Hepatobiliary and portal Venous interVentions

11. What can be done to manage the treatment of malignant biliary obstruction after

initial drainage?

With some tumor types, access to the bile ducts allows for the placement of radioactive isotopes for ductal

brachytherapy. If the patient is not a candidate for surgical resection, the drainage catheters may be left in long-term.

Sometimes, internal metal stents may be placed across malignant strictures to allow for catheter removal for patient

comfort. The decision to place a metallic stent depends on patient prognosis and life expectancy because internal metal

stents have limited long-term patency.

12. What does the term isolated ducts mean? What is its significance?

In the case of a low obstruction of the common bile duct, the right and left systems still communicate. A right-sided

biliary drain can be used to drain the right and the left sides. If the level of obstruction is higher, as might occur

with cholangiocarcinoma, this might not be the case, and some ducts may not communicate with others—they are

“isolated.” This is one reason why it is important to obtain cross-sectional imaging before biliary drainage. If only one

ductal system is dilated, this information helps determine the access site (left-sided drainage vs. right-sided drainage).

By definition, patients with isolated ducts have a portion of the biliary system that remains undrained if only a single

catheter is placed. These patients may require more than one tube to treat infection, pruritus, or hyperbilirubinemia.

13. How does stricture morphology help differentiate between benign and malignant

disease?

Benign strictures tend to taper smoothly, with gradual narrowing across their length. Malignant strictures, by contrast,

are points of obstruction that end abruptly, sometimes with irregular borders or an appearance of “shouldering.”

14. If a histologic diagnosis is required, what methods may be used to obtain a biopsy

specimen of the bile ducts?

When access to the bile ducts has been achieved, biopsy of a stricture site may be performed under fluoroscopic

guidance. Various devices may be used to obtain tissue samples, including biopsy brushes, forceps, and needles.

Often, several samples obtained on different days are required to obtain a diagnosis.

15. When is percutaneous cholecystostomy indicated?

Although cholecystectomy is the preferred therapy for acute cholecystitis, some patients may not be surgical candidates

because of their overall clinical status, sepsis, or other comorbid conditions. Percutaneous cholecystostomy combined with

broad-spectrum antibiotic coverage is a temporizing measure until the patient’s clinical status may be optimized for surgery.

16. Name the basic steps involved in performing percutaneous cholecystostomy.

With ultrasound (US) guidance, the gallbladder is accessed with a needle. A wire is placed, and after tract dilation, a

drainage catheter is placed into the gallbladder and allowed to drain externally. A subcostal, transhepatic path to the

gallbladder is generally preferred because it may guard against bile leakage into the peritoneal space if the catheter is

inadvertently dislodged.

17. What are potential complications associated with percutaneous cholecystostomy?

Complications include hemorrhage, infection, bile peritonitis, and respiratory failure or aspiration related to

intraprocedural sedation. Pneumothorax is possible, but relatively rare if a subcostal approach can be used.

18. How long must a percutaneous cholecystostomy catheter remain within the

gallbladder before it can be removed?

Although some investigators have shown that catheters may sometimes be safely removed in less time, most believe

that the cholecystostomy catheter should stay within the gallbladder for at least 4 to 6 weeks. This allows time for

a mature tract to form between the gallbladder and skin surface in an effort to prevent bile leakage into the peritoneal

space when the catheter is removed.

19. Should the cholecystostomy catheter be placed to external drainage indefinitely?

In the acute phase, although there is evidence of active inflammation, the catheter should be maintained on external

drainage. In the setting of cholecystitis secondary to obstructing biliary calculi, the catheter should be maintained on

external drainage. In the setting of acalculous cholecystitis, the catheter may be capped to allow for internal drainage

after a cholangiogram is performed to document that there is no evidence of cystic duct obstruction.

20. When is transjugular liver biopsy indicated and preferred over percutaneous liver

biopsy?

Because a transjugular liver biopsy specimen is obtained from within a hepatic vein, bleeding complications resulting

from transgression of the liver capsule may be avoided. The transjugular procedure is indicated for patients with

Hepatobiliary and portal Venous interVentions

249

interVentional radiology

coagulopathies or platelet deficiency. Platelet dysfunction because of renal failure may also be an indication. In addition,

any other issue that may make percutaneous biopsy difficult or risky (e.g., ascites) would be a potential indication for

transjugular liver biopsy. Because transjugular biopsy cannot generally be used to obtain tissue from a specific liver lesion,

it is used only to obtain a tissue diagnosis for medical (diffuse) liver disease, such as viral hepatitis or transplant rejection.

21. How is transjugular liver biopsy performed?

A hepatic vein (most commonly, the right hepatic vein) is accessed using a transjugular approach (jugular vein to

superior vena cava, through right atrium to inferior vena cava, and into right hepatic vein), and a stiff wire is placed.

A stiff metal cannula is placed over the wire into the hepatic vein. An 18G or 19G core biopsy needle is placed through

the cannula and used to obtain multiple samples of liver tissue. Because the right hepatic vein courses posteriorly

through the right lobe, the needle is directed anteriorly to avoid transgression of the liver capsule. Because the middle

hepatic vein courses more anteriorly, however, lateral or posterior sampling may be safer with this approach.

22. What are the clinical signs and symptoms associated with portal hypertension?

Esophageal, gastric, mesenteric, and rectal varices may bleed in response to elevated portal pressures; mortality from

the initial bleeding episode may be 20% to 60%. Increased intrasinusoidal pressure may result in ascites and hepatic

hydrothorax. Hepatic encephalopathy, hepatorenal syndrome with renal dysfunction, and hepatopulmonary syndrome

with hypoxemia may also be encountered.

23. How can one indirectly estimate portal venous pressure to confirm the diagnosis

of portal hypertension?

Catheterization of a hepatic vein is performed via jugular or femoral vein access. The catheter is advanced until it obstructs

a small hepatic vein branch, or a balloon occlusion catheter is inflated within the hepatic vein to obstruct its outflow. The

wedged hepatic vein pressure is actually a measure of sinusoidal pressure, but allows for a reasonable indirect estimate of

portal pressure. A corrected sinusoidal pressure measurement is obtained by subtracting the measured free hepatic venous

pressure from the wedged hepatic venous pressure. Corrected sinusoidal pressure measurements less than or equal to

5 mm Hg are considered normal. Measurements of 6 to 10 mm Hg are compatible with mild portal hypertension, and

measurements greater than 10 mm Hg are compatible with more severe portal hypertension.

24. What are the indications for creating a transjugular intrahepatic portosystemic shunt

(TIPS)?

The most common indication for TIPS placement is variceal bleeding related to portal hypertension that is refractory to

endoscopic therapy (

Fig. 34-5

). Other indications include refractory ascites or hepatic hydrothorax, Budd-Chiari syndrome,

portal hypertensive gastropathy, and hepatorenal or hepatopulmonary syndrome. TIPS placement may be an effective

bridge to liver transplantation for patients with end-stage liver disease and manifestations of portal hypertension.

25. What are the contraindications to

TIPS creation?

A pre-TIPS total bilirubin level greater than 3 mg/

dL, refractory coagulopathy with an international

normalized ratio greater than 1.8, a Child-Pugh

score greater than 12, and a serum creatinine level

greater than 1.9 mg/dL all have been found to be

associated with poor outcomes. TIPS creation that is

performed on an emergent basis is also associated

with high mortality, and hemodynamic stabilization

with transfusions, other medical interventions, and

balloon tamponade of gastroesophageal varices are

preferred before the TIPS procedure.

26. Describe the steps of the TIPS

procedure.

•

A hepatic vein, most commonly the right hepatic vein,

is accessed via a right internal jugular vein approach.

A wedged hepatic venogram may be obtained to

opacify the portal vein and map its location.

•

A stiff metal cannula is placed, and a needle

is passed from the right hepatic vein into the

right portal vein under fluoroscopic guidance.

Often, several needle passes are required to

obtain portal access. The portosystemic pressure

gradient measurement is obtained.

Figure 34-5.

TIPS with a stent from the right hepatic vein to the right

portal vein.

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Hepatobiliary and portal Venous interVentions

•

A stiff wire is placed into the portal vein, and dilation of the intrahepatic parenchymal tract is performed with an

angioplasty balloon.

•

A flexible, self-expanding stent (usually 8 or 10 mm in diameter) is placed from the portal vein to the confluence of

the hepatic vein with the inferior vena cava.

•

A venogram and repeat portosystemic pressure gradient measurements are obtained.

27. What are the potential complications of TIPS creation?

Complications include hemorrhage, infection, allergic reaction to contrast agent, and respiratory failure or aspiration

because of intraprocedural sedation. In addition, because the TIPS causes shunting of portal venous blood away from

the liver, the procedure may be complicated by decline in liver function and hepatic encephalopathy.

28. What are the short-term and long-term goals of TIPS creation?

Successful TIPS creation is associated with a final portosystemic pressure gradient measurement of less than

12 mm Hg to prevent variceal bleeding. If the TIPS has been placed to treat refractory ascites, lower pressures may

be necessary for success (

≤8 mm Hg). If the patient has significant encephalopathy, and treatment with lactulose is

insufficient to control symptoms, a reducing stent may be placed into the TIPS to create an intentional increase in the

portosystemic pressure gradient. TIPS patency should be monitored at intervals using duplex Doppler US, which allows

velocity measurements within the TIPS to be obtained noninvasively. Significant velocity increases from baseline may

indicate the presence of TIPS stenosis, which may prompt TIPS venography and revision by balloon dilation or additional

stent placement.

B

iBliography

[1] J.M. LaBerge, A.C. Venbrux (Eds.), SCVIR Syllabus: Biliary Interventions, SCVIR, Fairfax, VA, 1995.

[2] N.H. Patel, Z.J. Haskal, R.K. Kerlan (Eds.), SCVIR Syllabus: Portal Hypertension: Diagnosis and Interventions, second ed., SCVIR, Fairfax, VA,

2001.