Gastrointestinal and Urinary
Procedure Guide
Indications
Abnormal liver function tests in the setting of increased bleeding risk or need to obtain hepatic venous pressure measurements. Sometimes recommended over the percutaneous approach if perihepatic ascites is present to decrease bleeding risk, though a paracentesis can be performed prior to percutaneous biopsy.
Contraindications
No absolute contraindication but should try to correct platelets to >20K and INR <3.5.
Efficacy and alternatives
Adequate tissue for diagnosis achieved in nearly 100%
Classic teaching was that the transjugular approach has less bleeding risk than percutaneous random liver biopsy. However, newer studies suggest they have similar risks including bleeding but more patient discomfort, radiation, and procedure time with the transjugular approach.
Pre-procedure care
CBC and PT/INR for bleeding risk.
Review cross-sectional imaging if available for venous anatomy.
Review operative note if prior hepatic transplant for anastomosis morphology (piggyback vs end to end anastomosis).
Piggyback = donor IVC is connected to the recipient IVC end to side and the caudal donor IVC is sewn shut in a blind ending pouch.
End to end = donor IVC is connected end to end with the cavoatrial junction superiorly and recipient infrahepatic IVC inferiorly.
NOTE: venous congestion from anastomotic stenosis can be an early cause of graft dysfunction. It is often missed on US as only dampening of hepatic venous waveforms and missed on pathology unless pathologists know this is a concern. As such, some advocate to always do the transjugular approach for early graft dysfunction with pressure measurements including pull back pressure measurements across the anastomosis.
procedure
Right IJ access (can use left IJ, either EJ, or femoral access if necessary).
Advance stiff working wire (e.g. Amplatz) into the IVC.
Dilate access and advance sheath into right atrium (RA) +/- IVC for pressure measurement.
Select the right hepatic vein, often MPA, C2, or catheter in the kit with an angled glidewire. Middle or left hepatic vein can also be used if right is unfavorable.
Some leave the working wire in the IVC while selecting the hepatic vein.
Helpful to pull the sheath back far enough into the RA to not limit the curve of the catheter. Often the confluence of the hepatic veins and IVC is right at the inferior cavoatrial junction so may need to probe more superiorly if having trouble selecting the hepatic veins.
Confirm hepatic vein selection with venogram +/- lateral view (RHV should course posteriorly).
Puff with contrast prior to venogram to ensure the catheter is not wedged. Powerful injection while wedged can cause laceration and capsular rupture.
Obtain wedged and free hepatic venous pressure measurements.
According to Braveno VII workshop, use of end-hole compliant balloon occlusion catheter is recommended with small contrast injection after inflation to confirm. Others just use the access catheter, wedging it in 2-3 places and confirming wedging with GENTLE contrast injection.
Deep sedation can cause inaccurate measurement.
Requires measurement for at least a minute for stable tracing.
Free hepatic should be measurement within 2-3 cm of confluence with IVC.
Jugular approach:
Advance sheath into hepatic vein over the wire and catheter to secure access.
Remove catheter and advance curved metal introducer to end of the sheath in the hepatic vein followed by the biopsy device within the metal stiffener.
Unsheath 1-2 cm of the metal introducer and adjust to take sample ~1 vertebral body width lateral to the spine.
Turn introducer ~45 degrees anterior if from RVH or posterior from MHV. Advance biopsy device, obtain sample, and retract back into the introducer before releasing the anterior or posterior turn of the introducer as the biopsy device can lacerate the liver.
Aim for at least 3 good cores rinsing the biopsy needle in sterile saline between passes.
Femoral approach:
Similar to above but samples obtained from intrahepatic IVC.
Optional cavogram to confirm level of intrahepatic IVC.
The metal introducer often needs to be bent further to exaggerate to curve close to 90 degrees.
The introducer is pointed right laterally within the intrahepatic IVC with samples obtained similar to above.
Remove introducer and sheath and obtain hemostasis.
Complications
Minor (~6.2%): hematoma, bleeding, contrast/sedation reaction, new SVT
Major (~0.5%): often 2/2 capsular puncture and hemoperitoneum (0.4-0.6%) or ventricular arrhythmia -> death in 0.09%
Post-procedure care & Follow Up
Return care to primary team / referring clinician