Transjugular liver biopsy

INTRODUCTION — Despite the progress and advances in clinical medicine, biochemical analysis, and diagnostic imaging, histologic examination of hepatic tissue still has an important role in the management of patients with liver diseases. Percutaneous liver biopsy has proven to be fast, safe, and efficient, to the point of becoming the gold standard for liver tissue sampling.

However, percutaneous liver biopsy involves transection of the liver capsule, and patients taking anticoagulants or with coagulopathies are at an increased risk for intraperitoneal hemorrhage (table 1). Other factors such as obesity and high-volume ascites also represent a challenge for the percutaneous approach, increasing the risks associated with the procedure. Consequently, alternative techniques such as transjugular liver biopsy were developed to permit harvesting of liver tissue in patients with contraindications to the percutaneous procedure [1,2]. (See "Approach to liver biopsy".)

This topic will review transjugular liver biopsy. Percutaneous liver biopsy, transjugular intrahepatic portosystemic shunting, and the interpretation of biopsy specimens are discussed separately. (See "Approach to liver biopsy" and "Comparison of methods for endovenous ablation for chronic venous disease" and "Interpretation of nontargeted liver biopsy findings in adults" and "Overview of transjugular intrahepatic portosystemic shunts (TIPS)".)

INDICATIONS AND CONTRAINDICATIONS — Liver biopsy provides useful information that can be used for the diagnosis, prognosis, staging, and management of patients with acute or chronic liver diseases (table 2). Indications for biopsy include characterization of parenchymal liver diseases, evaluation of abnormal liver function studies, characterization of abnormalities seen on imaging studies, detection and staging of adverse effects of drug treatment, evaluation of liver status following transplantation, evaluation of acute liver failure, and evaluation of fever of unknown origin.

Unlike a percutaneous biopsy, the transjugular approach accesses the liver parenchyma through the superior vena cava and hepatic vein and obtains hepatic tissue without traversing the liver capsule. Possible bleeding from the biopsy site is directed into the access vein, minimizing the risk of intraperitoneal hemorrhage. Thus, multiple samples can be obtained with this technique in patients with abnormal hemostasis without increased risk for adverse events [3]. (See "Hemostatic abnormalities in patients with liver disease".)

Transjugular liver biopsy is safe and well tolerated and is generally the first-line option for patients in whom the percutaneous approach is suboptimal, contraindicated, or has previously failed (table 1 and table 3) [1,4-11]. In addition, transjugular access directly into the hepatic vein allows the hepatic venous pressure gradient to be measured (HVPG). The HVPG can be used to predict a patient's risk of developing varices or variceal bleeding and to guide the management of patients with portal hypertension due to cirrhosis. Finally, a transjugular approach can also be used in patients with a simultaneous indication for transjugular intrahepatic portosystemic shunt (TIPS) placement. (See "Primary prevention of bleeding from esophageal varices in patients with cirrhosis".)

Transjugular liver biopsy has been performed for patients with TIPS or direct portocaval shunt and for patients with left lobe-only liver transplants (via the left hepatic vein) [12,13]. However, this approach may not be feasible in patients with stenosis or occlusion of the right jugular vein, vena cava, or hepatic veins, such as those with Budd Chiari syndrome.

The conventional transjugular liver biopsy technique results in a non-targeted biopsy and is usually reserved for diffuse liver diseases. The transjugular approach should not be used if a targeted tissue sample is required. Instead, such patients require a targeted biopsy using a technique such as ultrasound-guided percutaneous biopsy, or a biopsy obtained during laparoscopy. (See "Approach to liver biopsy", section on 'Role of image guidance for nontargeted biopsies' and "Approach to liver biopsy", section on 'Laparoscopic liver biopsy'.)

Since the technique requires administration of intravenous contrast material, relative contraindications to transjugular liver biopsy also include the presence of renal failure and a history of prior adverse reaction to iodinated contrast material.

TECHNIQUE — Prior to the biopsy, a physical examination and review of the clinical history, laboratory results, imaging findings, current medications, and allergy history are performed. Written informed consent should be obtained, explaining the procedure and the risks and benefits that may be expected. Wherever possible, pre-existing coagulopathies should be corrected, and anticoagulants should be discontinued. (See "Informed procedural consent".)

The procedure is performed under local anesthesia with moderate procedural sedation. There is no consensus regarding the need for antibiotic prophylaxis for transjugular liver biopsy [14]. The Society for Interventional Radiology notes that antibiotic prophylaxis for transjugular intrahepatic portosystemic shunt placement with an antibiotic such as ceftriaxone is appropriate, but it does not comment on the use of antibiotics in patients undergoing transjugular liver biopsy. In the absence of clear guidelines, antibiotic prophylaxis may be administered at the discretion of the interventionalist. Our approach is to provide antibiotic prophylaxis with an antibiotic such as cefazolin or ceftriaxone when performing transjugular liver biopsies. The patient's hemodynamic parameters should be monitored throughout the procedure. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Patients are placed in a supine position on the angiography table with their neck exposed and their head turned away from the side of venous access. The right internal jugular vein (IJ) puncture is preferred because it offers more direct access to the superior vena cava (SVC), inferior vena cava (IVC), and the hepatic veins, facilitating the selective catheterization of the latter [15]. The right neck is prepared and draped in standard sterile fashion, and after administration of local anesthesia, intravenous access is obtained under ultrasonographic guidance with a micropuncture needle set using the Seldinger technique. (See "Central venous access in adults: General principles".)

The guidewire is advanced into the IVC under fluoroscopic guidance, followed by a transjugular vascular sheath. Selective catheterization of the right hepatic vein is performed through the vascular sheath with a combination of a hydrophilic guidewire and a 5 French multipurpose curved catheter. The right hepatic vein is usually selected because of its favorable orientation, but the biopsy can also be safely performed through the middle hepatic vein. The catheter is then advanced over the wire into the right hepatic vein, and a venogram is obtained to depict the venous anatomy (image 1). The hepatic venous pressure gradient can be measured at this point if indicated. The venous pressure is recorded with the catheter in both wedged and free hepatic vein positions to estimate the pressure gradient between the portal and systemic circulations, respectively. Alternatively, the estimated portal venous pressure can be measured using an occlusion balloon catheter.

A stiff guidewire is then inserted through the catheter into the right hepatic vein, over which the vascular sheath can be directed into the hepatic circulation. Next, a 7 French catheter with a curved metallic cannula is advanced through the vascular sheath and over the guidewire into the right hepatic vein under fluoroscopic guidance (image 2). Confirmation of adequate positioning into the hepatic vein approximately 4 cm distal to the IVC can be performed by injecting a small amount of iodinated contrast material. Keeping the sheath and catheter in place, the biopsy needle is inserted coaxially into the access assembly and advanced to the tip of the catheter. The catheter with the metallic cannula is then rotated in the desired direction, away from the center of vessel lumen, toward the liver parenchyma (image 3). The biopsy device is advanced out of the tip of the catheter, through the wall of the hepatic vein, and into the liver parenchyma. Once the biopsy device is within the liver parenchyma, a tissue sample is harvested with the semi-automated spring-fire mechanism (image 4). Usually three adequate samples (at least 15 mm in length) are obtained.

The biopsy may be performed under fluoroscopic guidance to avoid a deep puncture that could potentially perforate the liver capsule and cause bleeding complications. Our practice is to perform transjugular liver biopsies under real-time fluoroscopic guidance in order to increase safety and provide better control during needle advancement. This is particularly important in patients with small, cirrhotic livers, as there is a reduced distance between the hepatic vein and the liver capsule.

After the biopsy, a hepatic venogram is often performed to exclude active extravasation. In the unlikely event of a venous bleed, embolization of the site with a gelatin sponge can be performed. Arterial bleeding after the biopsy is a more serious complication that is usually detected when the patient develops hemodynamic instability and a hematocrit drop following the procedure. Arterial bleeding often requires hepatic arteriogram with embolization of the bleeding site. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults", section on 'Embolization'.)

After the venogram (if done), the catheter, metallic cannula, and vascular sheath are then removed. Manual compression at the puncture site on the right neck is performed to achieve hemostasis.

EFFICACY — Obtaining adequate tissue is essential for accurate histological interpretation. According to current recommendations, the specimens should be at least 15 mm long and contain at least six complete portal tracts to be considered optimal for diagnosis of diffuse liver disease [1]. The diagnostic and prognostic value of liver biopsies is significantly improved when multiple liver specimens (at least three individual non-fragmented samples) are submitted for analysis [2,16,17]. In general, transjugular liver biopsies are diagnostic in 85 to 100 percent of cases [2,6,18,19]. (See "Interpretation of nontargeted liver biopsy findings in adults", section on 'General principles'.)

COMPLICATIONS — Complications from transjugular liver biopsy may be minor or severe (table 4) [20-26]. The reported overall complication rate from transjugular liver biopsy ranges from 1 to 20 percent, with an overall mortality of 0.1 to 0.5 percent [1,27-29]. Complications were observed in 2.5 percent of transjugular liver biopsies in a retrospective analysis of 601 procedures [6]. Minor complications such as abdominal pain and fever are usually managed conservatively, whereas major complications often require intervention.

Major complications include hemoperitoneum, hemobilia, and fistulas between hepatic vein, hepatic artery, portal vein, and biliary system. Capsular puncture and consequent intraperitoneal hemorrhage is a major concern in this population, with increased risk in patients with small cirrhotic livers [1]. Significant hemobilia and hemoperitoneum are managed by aggressive transfusion of red blood cells and fresh-frozen plasma. In patients who continue to have bleeding, diagnostic hepatic angiography and venography followed by coil embolization are indicated [6]. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Liver biopsy (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Transjugular liver biopsy is a safe and efficient alternative to obtain adequate liver tissue specimens for patients with diffuse liver disease when a percutaneous procedure is either suboptimal or contraindicated (table 1). Common indications include severe coagulopathy and massive ascites (table 2). In addition, hepatic venous pressure gradient readings can be obtained or a transjugular intrahepatic portosystemic shunt inserted during the procedure. (See 'Indications and contraindications' above.)

●Using the transjugular technique permits access to the liver parenchyma through the hepatic vein, avoiding hepatic capsule puncture/perforation. (See 'Technique' above.)

●The overall complication rate of transjugular liver biopsy ranges from 1 to 20 percent. Major complications include hemoperitoneum, hemobilia, and fistulas between hepatic vein, hepatic artery, portal vein, and biliary system (table 4). (See 'Complications' above.)