Biliary Stent Placement

Biliary Stent Placement

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Pre-Procedure

Indications:
• Primarily obstructive lesions not amenable to surgery
• Often times for palliation
• Improve liver function so patient can undergo chemotherapy
• Stents generally remain patent for longer than patient's life expectancy

Contraindications:
• Coagulopathy
• Some lesions not amenable to stenting
• Hilar obstruction can pose technical challenge

Antibiotics:
• Many operator give antibiotics prior to biliary stenting
• No consensus on whether to give antibiotics or which antibiotic to administer
• Piperacillin/tazobactam (Zosyn)
• 1 g ceftriaxone
• If PCN allergy, consider vancomycin or clindamycin


Procedure

Antibiotic prophylaxis:
• Many operators administer antibiotics prior to biliary stenting
SIR guidelines recommend antibiotic prophylaxis for PTC and routine exchanges
• 1 g ceftriaxone IV; (ii)
• 1.5 - 3 g ampicillin/sulbactam (Unasyn) IV
• Vancomycin or clindamycin for PCN allergy

Types of stents:
• Bare self-expandable metallic stents (SEMS): permanent. Made of nitinol or stainless steel
• Covered biliary stents: removable. Tubular mesh which does not endothelialize

Goal is to drain as much of liver volume as possible
Attempt to drain 50% or more of liver volume

Procedure steps:
Obtain access beyond stricture/occlusion
Position catheter within duodenum - inject to confirm position

Place sheath large enough to accomodate stent
• Consider upsizing sheath one French size
• Helpful to have option for injection around stent to identify proximal landing zone
• Also consider CO2 if stent is near occlusive within the sheath
• Helpful to use marking pigtail catheter for injection to determine length of stenosis and stent length
Place guidewire (Amplatz useful) across stenosis into bowel
Consider pre-dilation of the stricture

Stent placement
• Choose landing zone with ~2 cm proximal and distal to the stenosis
• Depending on stenosis, distal landing zone may be beyond ampulla in small bowel.
• Details of deployment will vary with each stent
• Maintain back tension on stent as they have tendency to migrate forward during deployment

Following successful deployment, inject contrast to confirm stent patency and position
Many operators will leave "safety" pigtail biliary drain within intrahepatic system following stent procedure
• Preserves biliary access
• Maximizes biliary drainage following procedure which may help reduce chance of sepsis
• Allows for capping trial after stenting: drains commonly capped next day if patient progressing well
• Following successful capping trial (duration operator dependent - between 1-5 days), remove drain
• Some operators will inject biliary drain final time to confirm stent patency and remove "safety" drain over-the-wire

Post-Procedure

Postprocedural care
• Depends on specifics of patient and procedure
• Many patients can be discharged same day following stenting if previous biliary drain was present and "safety" drain left within intrahepatic ducts
• Consider IV hydration

Complications:
• Biliary sepsis
• Hemorrhage: hemobilia, pseudoaneurysm, hematoma
• Stent occlusion: tumor ingrowth or external compression
• Stent migration

Follow-up:
• Expect LFTs and bilirubin to downtrend
• 50-60% patency rate of bare stents at 1 year
• Some report patency rates of 75% with covered stents
• No routine follow-up

Related Procedures

No related procedures.

 

References

[1] Kapoor BS, Mauri G, Lorenz JM. Management of Biliary Strictures: State-of-the-Art Review. Radiology. 2018;289(3):590‐603. doi:10.1148/radiol.2018172424
[2] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483‐1501.e2. doi:10.1016/j.jvir.2018.06.007
[3] Ahmed O, Mathevosian S, Arslan B. Biliary Interventions: Tools and Techniques of the Trade, Access, Cholangiography, Biopsy, Cholangioscopy, Cholangioplasty, Stenting, Stone Extraction, and Brachytherapy. Semin Intervent Radiol. 2016;33(4):283‐290. doi:10.1055/s-0036-1592327
[4] Tsetis D, Krokidis Μ, Negru D, Prassopoulos P. Malignant biliary obstruction: the current role of interventional radiology. Ann Gastroenterol. 2016;29(1):33-6.
[5] George C, Byass OR, Cast JE. Interventional radiology in the management of malignant biliary obstruction. World J Gastrointest Oncol. 2010;2(3):146‐150. doi:10.4251/wjgo.v2.i3.146
[6] Inal M, Akgül E, Aksungur E, Seydaoğlu G. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction: unilobar versus bilobar drainage. J Vasc Interv Radiol. 2003;14(11):1409‐1416. doi:10.1097/01.rvi.0000096762.74047.a6

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Percutaneous Metallic Biliary Stent Placement By Kevin Rice

Dr. Kevin M. Rice inserts a metallic Wallflex (Wallstent) biliary stent percutaneously into the common bile duct in a patient with malignant biliary obstruction.

 

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Seminars in Interventional Radiology (Apr 2016)

Biliary Interventions Tools and Techniques of the Trade, Access, Cholangiography, Biopsy, Cholangioscopy, Cholangioplasty, Stenting, Stone Extraction and Brachytherapy

We describe an overview of the instrumentation and technical approaches for several fundamental biliary interventional procedures, including percutaneous transhepatic cholangiography and internal/external biliary drainage, endobiliary biopsy techniques, cholangioscopy, cholangioplasty and biliary stenting, biliary stone extraction, and intraluminal brachytherapy.

 

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