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Transjugular liver biopsy: A review of 200 biopsies
Clinical Radiology(1992)45, 238 239
Transjugular Liver Biopsy: A Review of 200 Biopsies P. CORR, S_ J. B E N I N G F I E L D and N. DAVEY
Department of Radiology, Groote Schuur Hospital/University of Cape Town, Observatory 7925, Cape Town, South Africa Transjugular liver biopsy was performed in 200 patients for whom percutaneous biopsy was contraindicated because of coagulation disorders (36%), ascites (32%) or for the work-up of portal hypertension (32%). An adequate biopsy allowing a histological diagnosis was obtained in 155 patients (77%). The biopsy was inadequate in 13 patients (6.5%). In 32 patients (16%) the biopsy failed. Complications occurred in 18 patients (9%). Twelve (6%) patients developed liver capsule perforations which were immediately embolized without complication. Inadvertent carotid artery puncture and supraventricular tachycardias occurred in three patients each. Transjugular liver biopsy is a valuable technique which provides information which would otherwise be unavailable in those patients for whom percutaneous biopsy is considered unsafe. Corr, P., Beningfield, S.J. & Davey, N. (1992). Clinical Radiology 45, 238-239. Transjugular Liver Biopsy: A Review of 200 Biopsies
Transjugular liver biopsy is a well established technique in those patients for whom percutaneous liver biopsy is contraindicated_ Contraindications to percutaneous biopsy include coagulation disorders and massive ascites. We report our experience over a 5 year period. P A T I E N T S AND M E T H O D S We reviewed the case records of 200 patients who had transjugular liver biopsies performed between 1986 and 1990. Clinical information evaluated included: the indication for biopsy~ the clinical diagnosis, clotting profile and the presence of ascites and jaundice. The clinical notes were checked for post-biopsy complications. The histopathology was assessed for the adequacy of the biopsy specimen, the presence o f fragmentation and the pathological diagnosis. We used the same technique of biopsy as described by Gamble et al. (1985). We routinely used a wedge beneath the patient to elevate the feet to distend the jugular veins. This facilitates the jugular vein puncture. The right internal jugular vein was routinely used for venous access. We found the use of ultrasound-guided puncture using a 5 MHz transducer extremely valuable in those patients in whom initial puncture was unsuccessful to establish the patency and position of the internal jugular vein. The puncture site was immediately anterior to the sternomastoid muscle, halfway between the mastoid process and sternal notch. We dilatated to tract to 9 F and used a 9 F transjugular catheter (Cook, Bloomington, IN) over a 0.035 in guide-wire which was advanced using fluoroscopy into the inferior vena cava (IVC) and then the right hepatic vein. Electrocardiographic monitoring is mandatory to detect arrhythmias as the catheter passes through the right atrium. Pressure measurements were obtained from the superior and inferior vena cavae, the right atrium and hepatic veins in the wedged and free position. The corrected sinusoidal pressure (CSP) was calculated by subtracting the free from the wedged hepatic vein pressure. Biopsy was performed using the modified Ross tranCorrespondenceto: Dr P. Corr, Department of Radiology,Prince of Wales Hospital, Sha Tin, Hong Kong.
septal needle with a central styler_ The catheter was preferably situated centrally in the vein rather than in a wedged peripheral site to reduce the incidence of capsule perforation. Contrast medium was injected down the catheter after biopsy to detect the presence of a capsular perforation. If there was a perforation the catheter was advanced and track embolized with two small Gelfoam pledgelets. After the biopsy the catheter was withdrawn with the patient sitting up and gentle pressure was applied to the puncture site for a few minutes. The patient was kept in the upright position for 6 h after the procedure. RESULTS Most patients presented with a clinical diagnosis of chronic liver disease (70%)_ The commonest single cause was alcohol related liver disease (40%). Coagulation disorders were the commonest indication for transjugular biopsy (36%), followed by marked ascites (32%). In the remaining patients (32%) transjugular biopsy was performed in addition to hepatic vein pressure measurements in the work-up of patients with oesophageal varices and portal hypertension. CSP were measured at the time of biopsy in 170 patients. In 120 patients (70%) there was some degree of portal hypertension (CSP > 5 mmHg). Fifty-one patients (30%) had severe portal hypertension (CSP > 15 mmHg). A biopsy specimen was obtained in 168 patients (84%). The biopsy was considered adequate for histology in 155 patients (77%) and insufficient in 13 patients (6.5%). In 31 patients (15%) the biopsy was fragmented, particularly in those patients with cirrhosis. Most biopsies were obtained after a single needle pass and in 95% of patients after three needle passes_ The commonest histological finding was micronodular cirrhosis in 59 patients (34%), followed by hepatitis in 27 patients (16%). Seventeen patients (10%) had normal histology. DISCUSSION Liver biopsy can be performed by fine needle aspiration using a 20 G or 22 G needle. However, with parenchymal
TRANSJUGULAR LIVER BIOPSY
or infiltrative-liver disease an adequate histological specimen using a large cutting needle biopsy is required. The needle tract can be embolized with Gelfoam pledgelets or steel coils to prevent a bile leak or pericapsular haemorrhage (Allison and Adam, 1988). However, in patients with clotting disorders and marked ascites, transjugular liver biopsy is a safe alternative procedure to plugged liver biopsy (Dick, 1990). The first transjugular liver biopsy was performed 24 years ago (Hanafee and Weiner, 1967). Since then, modifications in the design of the Ross transeptal needle by reversing the angle of the bevel and using a central stylet (Colapinto and Blendis, 1983) have improved the biopsy success rate to 92% (Gamble et al., 1985). Our success rate of 77% is comparable with previous series which vary from 64% to 97%. An adequate biopsy was only obtained in 77% of our patients largely because of the high incidence of biopsy fragmentation. Fragmentation commonly occurs from biopsies of cirrhotic livers as seen in 20% of our patients with cirrhosis. This results in suboptimal histological evaluation of the liver architecture_ In this situation the plugged liver biopsy method is a useful alternative procedure that should be used if transjugular biopsy fails. Capsular p~rforations were the most serious complication in our series. They were readily detected in 6% of our patients after biopsy by injecting contrast medium down the catheter into the needle track. Immediate embolization of the needle track with Gelfoam pledgelets after detection made the development of a haemoperitoneum less likely. This was the major complication in previous series (Lebrec et al., 1982; Bull et al., 1983). We support the belief that biopsy with the catheter wedged centrally on the wall of the right hepatic vein reduces the occurrence of capsule perforation (Gamble et al., 1985). Unfortunately, if the liver is small, as in severe cirrhosis, capsular perforation may be unavoidable. However, routine contrast injection down the catheter post-biopsy will detect this complication and the perforation can then be occluded (Braillon et al., 1986). Transient pyrexia described in previous series was not seen in our patients.
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Transient supraventricular tachycardia is easily recognized with electrocardiographic monitoring and will usually resolve on removing the catheter or guide-wire from the right atrium. We found ultrasound-guided puncture of the jugular vein particularly helpful in patients where venous access is difficult. Use of ultrasound guidance reduced the incidence of inadvertent carotid artery puncture to less than 2%. Inadvertent puncture of the carotid artery is seen in 5 % of patients undergoing central venous catheter placement by anaesthetists (Korshin et al., 1978). Transjugular biopsy requires that the radiologist has some experience in interventional techniques before attempting this procedure. However, we are convinced that this is a valuable technique in those patients in whom percutaneous biopsy is considered unsafe.
REFERENCES Allison, D & Adam, A (1988). Percutaneous liver biopsy and tract embolization with steel coils. Radiology, 169, 261--263. Braillon, A, Revert, R, Remond, A, Auderbert, M & Capron J (1986). Transcatheter embolization of liver capsule perforation during transvenous liver biopsy. Gastrointestinal Radiology, 11,277 279. Bull, H, Gilmore, I, Bradley, R, Marigold, J & Thompson, R (1983). Experience with transjugular liver biopsy. Gut, 24, 1057-1060. Colapinto, R & Blendis, L (1983). Liver biopsy through the transjugular approach: modification of instruments. Radiology, 148, 306. Dick, R (1990). Interventional radiology in obstructive jaundice. In: Imaging of the Liver, Pancreas and Spleen, eds Wilkins, R & Nunnerley, H, pp. 330-356. Blackwell Scientific Publications, Oxford. Gamble, P, Colapinto, R, Stronell, R, Colman, J ~1: Blendis, L (1985). Transjugular liver biopsy: a review of 461 biopsies. Radiology, 157, 589-593. Hanafee, W & Weiner M (1967). Transjugular percutaneous cholangiography. Radiology, 88, 35-39. Korshin, P, Klaubcr, P, Christensen, V & Scorsted, P (1978). Percutaneous catheterization of the internal jugular vein. Aeta Anaestheslologica Seandinavica, 67(Suppl.), 27-33. Lebrec, D, Goldfarb, G, Degott, C, Rueff, B & Benhamou, J (1982). Transvenous liver biopsy. An experience based on 1000 hepatic tissue samplings with this procedure. Gastroenterology, 83, 338 340.
Transjugular Liver Biopsy: A Review of 200 Biopsies P. CORR, S_ J. B E N I N G F I E L D and N. DAVEY
Department of Radiology, Groote Schuur Hospital/University of Cape Town, Observatory 7925, Cape Town, South Africa Transjugular liver biopsy was performed in 200 patients for whom percutaneous biopsy was contraindicated because of coagulation disorders (36%), ascites (32%) or for the work-up of portal hypertension (32%). An adequate biopsy allowing a histological diagnosis was obtained in 155 patients (77%). The biopsy was inadequate in 13 patients (6.5%). In 32 patients (16%) the biopsy failed. Complications occurred in 18 patients (9%). Twelve (6%) patients developed liver capsule perforations which were immediately embolized without complication. Inadvertent carotid artery puncture and supraventricular tachycardias occurred in three patients each. Transjugular liver biopsy is a valuable technique which provides information which would otherwise be unavailable in those patients for whom percutaneous biopsy is considered unsafe. Corr, P., Beningfield, S.J. & Davey, N. (1992). Clinical Radiology 45, 238-239. Transjugular Liver Biopsy: A Review of 200 Biopsies
Transjugular liver biopsy is a well established technique in those patients for whom percutaneous liver biopsy is contraindicated_ Contraindications to percutaneous biopsy include coagulation disorders and massive ascites. We report our experience over a 5 year period. P A T I E N T S AND M E T H O D S We reviewed the case records of 200 patients who had transjugular liver biopsies performed between 1986 and 1990. Clinical information evaluated included: the indication for biopsy~ the clinical diagnosis, clotting profile and the presence of ascites and jaundice. The clinical notes were checked for post-biopsy complications. The histopathology was assessed for the adequacy of the biopsy specimen, the presence o f fragmentation and the pathological diagnosis. We used the same technique of biopsy as described by Gamble et al. (1985). We routinely used a wedge beneath the patient to elevate the feet to distend the jugular veins. This facilitates the jugular vein puncture. The right internal jugular vein was routinely used for venous access. We found the use of ultrasound-guided puncture using a 5 MHz transducer extremely valuable in those patients in whom initial puncture was unsuccessful to establish the patency and position of the internal jugular vein. The puncture site was immediately anterior to the sternomastoid muscle, halfway between the mastoid process and sternal notch. We dilatated to tract to 9 F and used a 9 F transjugular catheter (Cook, Bloomington, IN) over a 0.035 in guide-wire which was advanced using fluoroscopy into the inferior vena cava (IVC) and then the right hepatic vein. Electrocardiographic monitoring is mandatory to detect arrhythmias as the catheter passes through the right atrium. Pressure measurements were obtained from the superior and inferior vena cavae, the right atrium and hepatic veins in the wedged and free position. The corrected sinusoidal pressure (CSP) was calculated by subtracting the free from the wedged hepatic vein pressure. Biopsy was performed using the modified Ross tranCorrespondenceto: Dr P. Corr, Department of Radiology,Prince of Wales Hospital, Sha Tin, Hong Kong.
septal needle with a central styler_ The catheter was preferably situated centrally in the vein rather than in a wedged peripheral site to reduce the incidence of capsule perforation. Contrast medium was injected down the catheter after biopsy to detect the presence of a capsular perforation. If there was a perforation the catheter was advanced and track embolized with two small Gelfoam pledgelets. After the biopsy the catheter was withdrawn with the patient sitting up and gentle pressure was applied to the puncture site for a few minutes. The patient was kept in the upright position for 6 h after the procedure. RESULTS Most patients presented with a clinical diagnosis of chronic liver disease (70%)_ The commonest single cause was alcohol related liver disease (40%). Coagulation disorders were the commonest indication for transjugular biopsy (36%), followed by marked ascites (32%). In the remaining patients (32%) transjugular biopsy was performed in addition to hepatic vein pressure measurements in the work-up of patients with oesophageal varices and portal hypertension. CSP were measured at the time of biopsy in 170 patients. In 120 patients (70%) there was some degree of portal hypertension (CSP > 5 mmHg). Fifty-one patients (30%) had severe portal hypertension (CSP > 15 mmHg). A biopsy specimen was obtained in 168 patients (84%). The biopsy was considered adequate for histology in 155 patients (77%) and insufficient in 13 patients (6.5%). In 31 patients (15%) the biopsy was fragmented, particularly in those patients with cirrhosis. Most biopsies were obtained after a single needle pass and in 95% of patients after three needle passes_ The commonest histological finding was micronodular cirrhosis in 59 patients (34%), followed by hepatitis in 27 patients (16%). Seventeen patients (10%) had normal histology. DISCUSSION Liver biopsy can be performed by fine needle aspiration using a 20 G or 22 G needle. However, with parenchymal
TRANSJUGULAR LIVER BIOPSY
or infiltrative-liver disease an adequate histological specimen using a large cutting needle biopsy is required. The needle tract can be embolized with Gelfoam pledgelets or steel coils to prevent a bile leak or pericapsular haemorrhage (Allison and Adam, 1988). However, in patients with clotting disorders and marked ascites, transjugular liver biopsy is a safe alternative procedure to plugged liver biopsy (Dick, 1990). The first transjugular liver biopsy was performed 24 years ago (Hanafee and Weiner, 1967). Since then, modifications in the design of the Ross transeptal needle by reversing the angle of the bevel and using a central stylet (Colapinto and Blendis, 1983) have improved the biopsy success rate to 92% (Gamble et al., 1985). Our success rate of 77% is comparable with previous series which vary from 64% to 97%. An adequate biopsy was only obtained in 77% of our patients largely because of the high incidence of biopsy fragmentation. Fragmentation commonly occurs from biopsies of cirrhotic livers as seen in 20% of our patients with cirrhosis. This results in suboptimal histological evaluation of the liver architecture_ In this situation the plugged liver biopsy method is a useful alternative procedure that should be used if transjugular biopsy fails. Capsular p~rforations were the most serious complication in our series. They were readily detected in 6% of our patients after biopsy by injecting contrast medium down the catheter into the needle track. Immediate embolization of the needle track with Gelfoam pledgelets after detection made the development of a haemoperitoneum less likely. This was the major complication in previous series (Lebrec et al., 1982; Bull et al., 1983). We support the belief that biopsy with the catheter wedged centrally on the wall of the right hepatic vein reduces the occurrence of capsule perforation (Gamble et al., 1985). Unfortunately, if the liver is small, as in severe cirrhosis, capsular perforation may be unavoidable. However, routine contrast injection down the catheter post-biopsy will detect this complication and the perforation can then be occluded (Braillon et al., 1986). Transient pyrexia described in previous series was not seen in our patients.
239
Transient supraventricular tachycardia is easily recognized with electrocardiographic monitoring and will usually resolve on removing the catheter or guide-wire from the right atrium. We found ultrasound-guided puncture of the jugular vein particularly helpful in patients where venous access is difficult. Use of ultrasound guidance reduced the incidence of inadvertent carotid artery puncture to less than 2%. Inadvertent puncture of the carotid artery is seen in 5 % of patients undergoing central venous catheter placement by anaesthetists (Korshin et al., 1978). Transjugular biopsy requires that the radiologist has some experience in interventional techniques before attempting this procedure. However, we are convinced that this is a valuable technique in those patients in whom percutaneous biopsy is considered unsafe.
REFERENCES Allison, D & Adam, A (1988). Percutaneous liver biopsy and tract embolization with steel coils. Radiology, 169, 261--263. Braillon, A, Revert, R, Remond, A, Auderbert, M & Capron J (1986). Transcatheter embolization of liver capsule perforation during transvenous liver biopsy. Gastrointestinal Radiology, 11,277 279. Bull, H, Gilmore, I, Bradley, R, Marigold, J & Thompson, R (1983). Experience with transjugular liver biopsy. Gut, 24, 1057-1060. Colapinto, R & Blendis, L (1983). Liver biopsy through the transjugular approach: modification of instruments. Radiology, 148, 306. Dick, R (1990). Interventional radiology in obstructive jaundice. In: Imaging of the Liver, Pancreas and Spleen, eds Wilkins, R & Nunnerley, H, pp. 330-356. Blackwell Scientific Publications, Oxford. Gamble, P, Colapinto, R, Stronell, R, Colman, J ~1: Blendis, L (1985). Transjugular liver biopsy: a review of 461 biopsies. Radiology, 157, 589-593. Hanafee, W & Weiner M (1967). Transjugular percutaneous cholangiography. Radiology, 88, 35-39. Korshin, P, Klaubcr, P, Christensen, V & Scorsted, P (1978). Percutaneous catheterization of the internal jugular vein. Aeta Anaestheslologica Seandinavica, 67(Suppl.), 27-33. Lebrec, D, Goldfarb, G, Degott, C, Rueff, B & Benhamou, J (1982). Transvenous liver biopsy. An experience based on 1000 hepatic tissue samplings with this procedure. Gastroenterology, 83, 338 340.