Transjugular Liver Biopsy

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

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

Preoperative 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


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

• 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.

• 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

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

• 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.

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!


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

• 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%

Related Procedures

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[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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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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Seminars in Interventional Radiology (Jun 2012)

Transjugular Liver Biopsy

The purpose of this article is to provide a review of the fundamental aspects of the TJLB procedure, including technique, indications, contraindications, results, and complications.

The Indian Journal of Radiology & Imaging (Jun 2008)

Transjugular Liver Biopsy: What To Do and What Not to Do.

This article description is not yet available.



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