Procedure Guide

Transjugular Liver Biopsy

Transjugular liver biopsy (TJLB) is a common procedure for obtaining liver tissue samples through a transvenous approach. Transjugular liver biopsy is helpful for obtaining non-targeted liver specimens for the diagnosis and staging of acute and/or chronic liver disease. TJLB has distinct advantages over percutaneous or endoscopic liver biopsy. Utilizing a transvenous approach allows the operator to avoid traversing the liver capsule in patients at high risk for post biopsy hemorrhage or ascites. Additionally, a transvenous approach allows for measuring the hepatic venous pressure gradient (HVPG) which serves as a tool for the diagnosis of portal hypertension. Transjugular liver biopsy can be an extremely common procedure particularly for operators working at liver transplant centers. Understanding the steps and nuances of the procedure will facilitate a safe and effective liver biopsy through the jugular vein in patients with liver disease ranging from minimal to life-threatening.

Step-by-step guidance on how to perform Transjugular Liver Biopsy. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre-Procedure Prep

Transjugular Liver Biopsy Indications

• Coagulopathy
• Ascites
• Severe obesity
• Hepatic peliosis
• Need for portal pressure measurements

Contraindications

• Few if any
• Occluded SVC and/or internal jugular veins
• Contrast allergy or renal insufficiency can be treated with CO2 angiography

Pre-Operative Evaluation

• H&P
• Indication for procedure and if portal pressures are needed
• History of prior liver resection or surgery

Prior imaging - US/CT/MRI
• Right hepatic patency and orientation relative to IVC and liver on prior imaging
• Presence of hepatic malignancy or cysts
• Not necessary before biopsy

Transjugular Liver Biopsy Procedure Steps

Procedure Steps

• Access right internal jugular vein
• Place 0.035" wire into IVC
• 9-Fr sheath into right atrium
• Take right atrial pressure
• Catheterize right hepatic vein (RHV)
• Venogram in RHV
• Take free hepatic pressure
• Advance MPA into wedged position
• Take wedged hepatic pressure
• Advance stiff wire into distal RHV
• 7-Fr catheter with 5-Fr catheter loaded advanced over the wire in the RHV
• Remove wire and 5-Fr catheter
• Biopsy device through 7-Fr sheath and take 3 cores
• Remove 7-Fr sheath and hold pressure

Access

• Right internal jugular vein most common
• Occasionally will have to access external jugular vein, left IJ or a femoral vein

Place 9 Fr sheath
• 23 cm or 35 cm length helpful. 9-Fr sheath can be advanced into RHV
• Consider BRITE TIP (Cordis) sheath

Catheterize RHV

• Multipurpose catheter (MPA) commonly used
• Probe catheter along the right lateral and posterolateral IVC wall to enter right hepatic vein.

Venogram

• If unsure on AP view whether catheter is in middle vs right hepatic vein, can check catheter location with lateral fluoroscopy
• Ok to biopsy from middle hepatic vein (MHV). Consider posterior direction for biopsy

Wires

• Many options will work
• Amplatz Super Stiff (Boston Scientific) with J tip

Biopsy

• 7-Fr sheath need constant downward pressure while in the RHV. Sheath has tendency to back out into IVC due to respiratory motion.
• Advance needle gently, under direct fluoroscopic observation down into the RHV.
• Direct needle anteriorly and obtain a specimen.
• Obtain 2-3 specimens. Specimens are placed in formalin.

Transjugular Liver Biopsy Pressure Measurements

• Obtain right atrial pressure, free hepatic venous pressure (FHVP) and wedged hepatic venous pressures (WHVP) - use mean measurements
• Wedged hepatic venous pressure (WHVP) should be taken with saline, not contrast in catheter
• Hepatic venous pressure gradient (HVPG): Difference between WHVP and FHVP
• Good article: Hepatic Venous Pressure Gradient Measurement: Time to Learn! https://indianjgastro.com/IJG_pdf/march2008/march08_pg74-80.pdf

Post-Procedure

Post-Procedural Care

• Observe patient for 3-6 hours
• Vital signs at least Q30 minutes

Complications

• Failure to obtain diagnostic specimen
• Cardiac arrhythmia due to prolapse of needle into right atrium
• Bile duct or gallbladder injury
• Hepatic artery injury by needle - may present with hemobilia and melena.
• Liver capsule puncture and hemoperitoneum
• Pneumothorax
• Mortality between 0-0.5%

Transjugular Liver Biopsy Demos

Transjugular Liver Biopsy (TJLB) Procedure in Chronic Liver Disease, Ascities, and Low Platelets

Dr. Shaileshkumar Garge demonstrates the steps of TJLB and discusses indications for the procedure.

Transjugular Liver Biopsy (TLAB) Procedure Video

Transjugular liver biopsy procedure conducted using the TLAB Transjugular Liver Biopsy System

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Transjugular Liver Biopsy (TJLB) Procedure in Chronic Liver Disease, Ascities, and Low Platelets

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References

[1] Sue MJ, Lee EW, Saab S, et al. Transjugular Liver Biopsy: Safe Even in Patients With Severe Coagulopathies and Multiple Biopsies. Clin Transl Gastroenterol. 2019;10(7):e00063. doi:10.14309/ctg.0000000000000063
[2] Dohan A, Guerrache Y, Boudiaf M, Gavini JP, Kaci R, Soyer P. Transjugular liver biopsy: indications, technique and results. Diagn Interv Imaging. 2014;95(1):11‐15. doi:10.1016/j.diii.2013.08.009
[3] Behrens G, Ferral H. Transjugular liver biopsy. Semin Intervent Radiol. 2012;29(2):111‐117. doi:10.1055/s-0032-1312572
[4] Behrens G, Ferral H, Giusto D, Patel J, Van Thiel DH. Transjugular liver biopsy: comparison of sample adequacy with the use of two automated needle systems. J Vasc Interv Radiol. 2011;22(3):341‐345. doi:10.1016/j.jvir.2010.10.012
[5] Keshava SN, Mammen T, Surendrababu N, Moses V. Transjugular liver biopsy: What to do and what not to do. Indian J Radiol Imaging. 2008;18(3):245‐248. doi:10.4103/0971-3026.41839
[6] Kumar A, Sharma P, Sarin SK. Hepatic venous pressure gradient measurement: time to learn!. Indian J Gastroenterol. 2008;27(2):74‐80.

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