Transjugular liver biopsy: a prospective study in 43 patients with the Quick-Core biopsy needle

Technical Success, Sample Adequacy, and Complications of Pediatric Transjugular Liver Biopsy: A Systematic Review and Meta-Analysis

BACKGROUND

Transjugular liver biopsy (TJLB) procedurally samples liver tissue through the internal jugular vein. It is indicated in the presence of coagulopathies and/or ascites.

AIMS

This meta-analysis aimed to assess the safety and efficacy of TJLB in children.

METHODS

A literature search of several databases was conducted from inception to August 2022. Eligible studies reported pediatric patients (< 18 years old) who underwent TJLB. The pooled proportion was analyzed using a random-effects model. This review was registered in PROSPERO (CRD42022354421).

RESULTS

From 921 initial studies screened, eight met the eligibility criteria, with a total of 361 pediatric patients who underwent 374 TJLBs. All eight studies reported pooled rates of technical success at 99.1% (95% CI 0.982, 1.001; I2 = 0%) and histological adequacy of sampling at 97.5% (95% CI 0.954, 0.995; I2 = 27.66%). A total of 49 complications were reported across six studies, the most common being bleeding from the entry site (38.78%), fevers for less than 24 h (12.24%), red blood cells transfusion requirement (10.2%), supraventricular tachycardia (8.16%), and pain requiring analgesia (8.16%).

CONCLUSION

Pediatric TJLB demonstrates high rates of technical success and adequate liver core biopsy samples, with a low rate of complications. These results suggest that TJLB is an effective method for diagnostic yield and postprocedural outcomes, especially in patients with preexisting coagulopathies and ascites where percutaneous liver biopsy is contraindicated. Additional studies evaluating larger groups of pediatric patients may provide further support for the use of TJLB in this population.

Plugged percutaneous biopsy of the liver in living-donor liver transplantation recipients suspected to have graft rejection

Background Percutaneous biopsy is a widely-accepted technique for acquiring histologic samples of the liver. When there is concern for bleeding, plugged percutaneous biopsy (PPB) may be performed, which involves embolization of the biopsy tract. Purpose To evaluate the efficacy and safety of PPB of the liver in patients suspected to have graft rejection after living-donor liver transplantation (LDLT). Material and Methods During January 2007 and December 2013, 51 patients who underwent PPB of the liver under the suspicion of post-LDLT graft rejection were retrospectively analyzed. A total of 73 biopsies were performed. Biopsy was performed with a 17-gauge core needle and 18-gauge cutting needle. The needle tract was embolized using gelatin sponge (n = 44) or N-butyl cyanoacrylate (NBCA) (n = 29). The specimens were reviewed to determine their adequacy for histologic diagnosis. We reviewed all medical records after PPB. Results Specimens were successfully acquired in all procedures (100%). They were adequate for diagnosis in 70 cases (95.9%) and inadequate in three (1.3%). Average of 9.8 complete portal tracts was counted per specimen. One minor complication (1.4%) occurred where the patient had transient fever after the procedure. Conclusion PPB is easy and safe to perform in LDLT recipients and provides high diagnostic yield.

Transjugular liver biopsy: results of 97 patients

OBJECTIVE

To evaluate the feasibility and efficacy of transjugular liver biopsy in patients with contraindicated percutaneous biopsy.

MATERIALS AND METHODS

Between June 2005 and April 2010, 97 patients who were admitted for transjugular liver biopsy were enrolled in this retrospective study. All liver biopsies were obtained using an 18 gauge Quick-Core liver biopsy set through the right hepatic vein via the internal jugular vein. Clinical indication, histopathological diagnosis, and complications were noted.

RESULTS

Primary technical success was achieved in 93 (95.8%) patients. Hepatic veins could not be catheterized and opacified in two patients and in the remaining two patients the veins could be opacified and catheterized but we were not able to pass the biopsy needle into the hepatic vein because of the acute angle between the inferior vena cava and hepatic veins. At least two specimens were obtained from each patient. The most frequent histopathological diagnosis was cirrhosis. A subcutaneous hematoma around the puncture side was encountered in one patient.

CONCLUSION

Transjugular liver biopsy is a feasible and effective alternative in patients with contraindication for percutaneous biopsy.

Two cases of major hemorrhage secondary to transjugular liver biopsy

Transjugular liver biopsy is an essential procedure in the armamentarium of the interventional radiologist for patients who otherwise are unable to undergo percutaneous liver biopsy. Multiple conditions exist that necessitate the transjugular approach for biopsy, including acquired coagulopathy, congenital blood disorders, or requirement for measurements of hepatic venous and/or wedged hepatic vein pressures. The safety and efficacy of transjugular liver biopsy is well established, with many studies citing extremely low rates of complication with high rates of technical success. Nonetheless, transjugular liver biopsy is not without complications. The most often reported complication is asymptomatic capsular perforation; however occasionally, major hemorrhagic complications and even death have been reported. We describe two major hemorrhagic complications that manifested several days after the procedure and required emergent intervention.

Impact of HIV on liver fibrosis in men with hepatitis C infection and haemophilia

Hepatitis C virus (HCV) is the major cause of liver disease in haemophilia. Few data exist on the proportion with liver fibrosis in this group after long-term HCV and HIV co-infection. We conducted a cross-sectional multi-centre study to determine the impact of HIV on the prevalence and risk factors for fibrosis in haemophilic men with chronic hepatitis C. Biopsies were independently scored by Ishak, Metavir and Knodell systems. Variables were tested for associations with fibrosis using logistic regression and receiver operating curves (ROC). Of 220 biopsied HCV(+) men, 23.6% had Metavir ≥ F3 fibrosis, with higher mean Metavir fibrosis scores among HIV/HCV co-infected than HCV mono-infected, 1.6 vs. 1.3 (P = 0.044). Variables significantly associated with fibrosis included AST, ALT, APRI score (AST/ULN × 100/platelet × 10(9) /L), alpha-fetoprotein (all P < 0.0001), platelets (P = 0.0003) and ferritin (P = 0.0008). In multiple logistic regression of serum markers, alpha-fetoprotein, APRI and ALT were significantly associated with ≥ F3 fibrosis [AUROC = 0.77 (95% CI 0.69, 0.86)]. Alpha-fetoprotein, APRI and ferritin were significant in HIV(-) [AUROC = 0.82 (95% CI 0.72, 0.92)], and alpha-fetoprotein and platelets in HIV(+) [AUROC = 0.77 (95% CI 0.65, 0.88]. In a multivariable model of demographic and clinical variables, transformed (natural logarithm) of alpha-fetoprotein (P = 0.0003), age (P = 0.006) and HCV treatment (P = 0.027) were significantly associated with fibrosis. Nearly one-fourth of haemophilic men have Metavir ≥ 3 fibrosis. The odds for developing fibrosis are increased in those with elevated alpha-fetoprotein, increasing age and past HCV treatment.

Interventional radiology procedures in adult patients who underwent liver transplantation

Interventional radiology has acquired a key role in every liver transplantation (LT) program by treating the majority of vascular and non-vascular post-transplant complications, improving graft and patient survival and avoiding, in the majority of cases, surgical revision and/or re-transplantation. The aim of this paper is to review indications, technical consideration, results achievable and potential complications of interventional radiology procedures after deceased donor LT and living related adult LT.

Transjugular liver biopsy using ultrasonographic guidance for jugular vein puncture and an automated device for hepatic tissue sampling: a retrospective analysis of 200 consecutive cases

BACKGROUND

We retrospectively evaluated the value of the combination of ultrasonographic guidance for jugular vein puncture and an automated biopsy device for transjugular liver biopsy.

METHODS

Transjugular liver biopsy was performed with ultrasonographic guidance for right internal jugular vein puncture and an automated device for hepatic tissue sampling (Quick-Core) in 200 consecutive patients in whom percutaneous transhepatic biopsy was contraindicated. Histopathologic specimens were reviewed for adequacy and complications related to the procedure were analyzed.

RESULTS

Biopsies were technically successful in 198 of 200 (99%) patients. The two cases of technical failure were due to an acute angle between right hepatic vein and inferior vena cava (1%). Adequate gross hepatic tissue specimens (mean length, 11. 0 mm +/- 5.3; range, 5.0-20.0 mm) were obtained in 198 (99%) patients, allowing definitive histological diagnosis in 196 of 198 patients, for an overall success rate of 98%. Neither cases of inadvertent injury of the carotid artery nor life-threatening intraperitoneal bleeding were observed. Minor complications were noted in 24/200 (12%) patients.

CONCLUSION

The combination of ultrasonographic guidance for jugular vein puncture and an automated biopsy device for tissue sampling is recommended for transjugular liver biopsy as it results in a safe, well-tolerated, and efficient technique.

Transjugular liver biopsy in patients with living donor liver transplantation: comparison with percutaneous biopsy

Transjugular liver biopsy (TJLB) is an alternative method of pathological diagnosis in patients with an established contraindication to percutaneous biopsy. Between November 2005 and July 2007, 111 TJLBs were attempted in 67 patients and 95 percutaneous liver biopsies (PCLBs) were attempted in 51 patients with living donor liver transplantation suspected of having rejection. Indications of TJLB included classic contraindications to PCLB and a postoperative period of less than 30 days. TJLB was performed a mean of 111.1 +/- 292.6 days after transplantation (range: 6-2478 days, median: 35 days), and PCLB was performed a mean of 534.7 +/- 591.6 days after transplantation (range: 6-2555 days, median: 299 days). Technical success was 99.1% in TJLB and 100% in PCLB, and there was no significant difference between these 2 groups (P = 0.354). A clinical suspicion of rejection was confirmed by histopathology in 38 (34.2%) of 111 TJLBs and 38 (40.0%) of 95 PCLBs. The overall complication rates related to the procedure were 1.8% (2/111) in TJLB and 5.3% (5/95) in PCLB. Although there was no significant difference in complication rates between TJLB and PCLB (P = 0.172), the patients who underwent TJLB showed significantly higher incidence of ascites, coagulopathy, and thrombocytopenia, given its indication. TJLB seems to be a safe and effective procedure for pathological diagnosis of rejection in patients with living donor liver transplantation when there is a high risk of complication with PCLB.

Transjugular biopsy of an atypical focal nodular hyperplasia in a patient with acute liver failure clinical presentation

The following is a report on one case of successful biopsy of a hepatic focal lesion incidentally found in an emergency computed tomography scan performed in a patient with acute liver failure clinical presentation. The presence of peri-hepatic ascites and severe coagulopathy contraindicated the percutaneous biopsy. The transjugular approach was used to perform a random liver biopsy to assess the amount of hepatic necrosis and to perform the focal lesion biopsy orienting the needle with sonography guidance. The specimen acquired was satisfactory to exclude the presence of malignant cells in the lesion; the diagnosis of atypical focal nodular hyperplasia was performed. The patient underwent successful liver transplantation the day after.

Transjugular liver biopsy--indications, adequacy, quality of specimens, and complications--a systematic review

Transjugular liver biopsy (TJLB) is considered an inferior biopsy, used when percutaneous liver biopsy (PLB) is contraindicated. According to recent literature, specimens with 6 complete portal tracts (CPTs) are needed for histological diagnosis of chronic liver disease but 11 CPTs to reliably stage and grade. Mean CPT number in PLB series is 7.5; more passes increase complications. Sixty-four series reporting 7649 TJLBs were evaluated for quality of specimen and safety. Major indications were coagulation disorders and/or ascites. Success rate was 96.8%. Fragmentation rate was 34.3%, not correlating with length or diagnostic adequacy. With a mean of 2.7 passes, mean CPT number was 6.8. Histological diagnosis was achieved in 96.1% of TJLBs, correlating with length (p=0.007) and CPT number (p=0.04). Tru-Cut specimens had a mean CPT number of 7.5 and, compared to Menghini specimens, were longer (p<0.008), less fragmented (p<0.001) and more diagnostic (p<0.001). Thinner needles (>16-G) provided significantly longer and less fragmented specimens. Minor and major complication rates were 6.5% and 0.56%, respectively, and increased in children, but not with additional passes. In adults, mortality was 0.09% (haemorrhage 0.06%; ventricular arrhythmia 0.03%). TJLB is safe, providing specimens qualitatively comparable to PLB, and may improve further using > or = 18-G Tru-Cut needle and >3 passes.

Contribution of transjugular liver biopsy in patients with the clinical presentation of acute liver failure

PURPOSE

Acute liver failure (ALF) treated with conservative therapy has a poor prognosis, although individual survival varies greatly. In these patients, the eligibility for liver transplantation must be quickly decided. The aim of this study was to assess the role of transjugular liver biopsy (TJLB) in the management of patients with the clinical presentation of ALF.

METHODS

Seventeen patients with the clinical presentation of ALF were referred to our institution during a 52 month period. A TJLB was performed using the Cook Quick-Core needle biopsy. Clinical data, procedural complications, and histologic findings were evaluated.

RESULTS

Causes of ALF were virus hepatitis B infection in 7 patients, drug toxicity in 4, mushroom in 1, Wilson's disease in 1, and unknown origin in 4. TJLB was technically successful in all patients without procedure-related complications. Tissue specimens were satisfactory for diagnosis in all cases. In 14 of 17 patients the initial clinical diagnosis was confirmed by TJLB; in 3 patients the initial diagnosis was altered by the presence of unknown cirrhosis. Seven patients with necrosis < 60% were successfully treated with medical therapy; 6 patients with submassive or massive necrosis (> or = 85%) were treated with liver transplantation. Four patients died, 3 had cirrhosis, and 1 had submassive necrosis. There was a strict statistical correlation (r = 0.972, p < 0.0001) between the amount of necrosis at the frozen section examination and the necrosis found at routine histologic examination. The average time for TJLB and frozen section examination was 80 min.

CONCLUSION

In patients with the clinical presentation of ALF, submassive or massive liver necrosis and cirrhosis are predictors of poor prognosis. TLJB using an automated device and frozen section examination can be a quick and effective tool in clinical decision-making, especially in deciding patient selection and the best timing for liver transplantation.

Transjugular liver biopsy via the left internal jugular vein

PURPOSE

To retrospectively review the indications and outcomes of transjugular liver biopsy (TJLB) with the left internal jugular vein (IJV) approach.

MATERIALS AND METHODS

A retrospective review of all TJLBs performed at one institution was performed. From August 1995 to October 2004, 293 liver biopsies were performed. Nineteen of the 293 procedures (6.5%) were performed from the left IJV in 17 patients. There were 11 men and six women aged 36-59 years (mean, 49.3 years). All patients were suspected of having diffuse hepatic parenchymal disease and had contraindications to conventional percutaneous liver biopsy. The stiff metal biopsy cannula was advanced across the mediastinum and through the heart over a stiff guide wire. Biopsy was performed from the right hepatic vein in 15 procedures, the middle hepatic vein in two, and the intrahepatic IVC in two.

RESULTS

The indications for using the left IJV approach were nonusable right IJV in 12 procedures, difficult previous catheterization of the hepatic veins from the right IJV due to distorted hepatic anatomy in six procedures, and the operator's predilection for this approach in one procedure (the patient had previously undergone liver transplantation). All biopsies were successful, with diagnostic tissue obtained in 100% of cases. Two patients had chest pain during the procedure associated with placement of the rigid cannula through the mediastinal veins. One patient had a vaso-vagal episode that necessitated the use of intravenous atropine but subsequently underwent successful biopsy. All episodes of chest pain resolved after the cannula was removed. There were no recorded hemorrhagic or cardiac complications.

CONCLUSION

TJLB can be safely and repeatedly performed from the left IJV when the right IJV is not available or the hepatic anatomy prevents catheterization of the hepatic veins from the right IJV.

Comparison of a new aspiration needle device and the Quick-Core biopsy needle for transjugular liver biopsy

AIM: To evaluate sample adequacy, safety, and needle passes of a new biopsy needle device compared to the Quick-Core biopsy needle for transjugular liver biopsy in patients affected by liver disease.

METHODS: Thirty consecutive liver-disease patients who had major coagulation abnormalities and/or relevant ascites underwent transjugular liver biopsy using either a new needle device (18 patients) or the Quick-Core biopsy needle (12 patients). The length of the specimens was measured before fixation. A pathologist reviewed the histological slides for sample adequacy and pathologic diagnoses. The two methods’ specimen adequacy and complication rates were assessed.

RESULTS: Liver biopsies were technically successful in all 30 (100%) patients, with diagnostic histological core specimens obtained in 30 of 30 (100%) patients, for an overall success rate of 100%. With the new device, 18 specimens were obtained, with an average of 1.1 passes per patient. Using the Quick-Core biopsy needle, 12 specimens were obtained, with an average of 1.8 passes per patient. Specimen length was significantly longer with the new needle device than with the Quick-Core biopsy needle (P < 0.05). The biopsy tissue was not fragmented in any of the specimens with the new aspiration needle device, but tissue was fragmented in 3 of 12 (25.0%) specimens obtained using the Quick-Core biopsy needle. Complications included cardiac arrhythmia in 3 (10.0%) patients, and transient abdominal pain in 4 (13.3%) patients. There were no cases of subcapsular hematoma, hemoperitoneum, or sepsis, and there was no death secondary to the procedure. In particular, no early or delayed major procedure-related complications were observed in any patient.

CONCLUSION: Transjugular liver biopsy is a safe and effective procedure, and there was significant difference in the adequacy of the specimens obtained using the new needle device compared to the Quick-Core biopsy needle. Using the new biopsy needle device, the specimens showed no tissue fragmentation and no increment in major procedure-related complications was observed.

A systematic review of the quality of liver biopsy specimens

Characteristics for an optimal liver biopsy specimen were recently defined as 20 to 25 mm long and/or containing more than 11 complete portal tracts (CPTs). A systematic review of percutaneous liver biopsy (PLB) and transjugular liver biopsy (TJLB) series yielded only 32 PLB studies in which these characteristics were evaluated: mean +/- SD length, 17.7 +/- 5.8 mm and number of CPTs, 7.5 +/- 3.4; and 15 TJLB studies: mean +/- SD length, 13.5 +/- 4.5 mm and number of CPTs, 6.8 +/- 2.3. Studies of sampling heterogeneity and intraobserver and interobserver variability also used inadequate specimens by present standards. Only 11 (5.3%) of 207 therapeutic studies for chronic hepatitis B and C documented length and/or number of CPTs. Of the current 12 studies evaluating noninvasive fibrosis tests, only 8 documented length or number of CPTs, and only 1 documented length and number of CPTs. New studies are needed based on adequate liver biopsy samples to provide reliable estimation of grading and staging in chronic liver disease.

Interventional radiology in liver transplantation

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.

Transvenous liver biopsy via the femoral vein

AIM

To study the safety, effectiveness and diagnostic value of transvenous forceps biopsy of the liver in 54 patients with coagulopathy, gross ascites or morbid obesity and suspected liver disease in whom percutaneous liver biopsy was contraindicated.

MATERIAL AND METHODS

Forceps biopsy of the liver via the femoral vein was attempted in 54 adult patients with advanced liver disease of unknown aetiology who had coagulation disorders (41 cases), gross ascites (11 cases) or morbid obesity (two cases). In each patient two to six biopsies (average four) were taken using a radial jaw forceps inserted via the right or left femoral vein.

RESULTS

The procedure was successful in 53 cases. Hepatic vein catheterization failed in one patient. Adequate liver tissue for diagnosis was obtained in 84% of cases. One patient developed delayed haemorrhage at 12 h from a capsular leak that was undetected during the biopsy procedure. This patient required blood transfusions and laparotomy to control bleeding. There were no deaths in the 53 patients studied. Transient minor chest and shoulder pain was encountered during sheath insertion into a hepatic vein in 23 patients. Three patients developed a femoral vein haematoma, which resolved with conservative treatment.

CONCLUSION

Transvenous liver biopsy via the femoral vein is another safe, effective, simple alternative technique of biopsy when the percutaneous route is contraindicated.

Transjugular liver biopsy: histological diagnosis success comparing the trucut to the modified aspiration Ross needle

BACKGROUND: Transjugular liver biopsy is an alternative procedure for patients who present contraindications to standard percutaneous procedure. AIM: To compare the rate of histological diagnosis obtained on transjugular liver biopsy with an automated trucut needle and with a modified Ross needle. PATIENTS / METHOD: Eighty-five patients with suspicion of chronic liver diseases and presenting contraindications for percutaneous liver biopsy (coagulopathy, massive ascites, morbid obesity, or chronic renal problems) were submitted to 89 transjugular liver biopsies between March 1994 and April 2001 at ''Hospital São José, Irmandade da Santa Casa de Misercórdia'', Porto Alegre, RS, Brazil. Thirty-five patients underwent 36 biopsies with an automated trucut needle, and 50 patients underwent 53 biopsies with a modified Ross needle. RESULTS: Histological diagnosis was reached in 32/35 subjects submitted to transjugular liver biopsy with the trucut needle (91%) and in 35/50 (70%) submitted to biopsy with the modified Ross needle. Specimens obtained with the trucut needle were significantly larger and less fragmented than those obtained with the Ross needle. CONCLUSION: Transjugular liver biopsy with the automated trucut needle allowed a higher rate of histological diagnosis when compared to the modified Ross needle in patients with suspicion of chronic liver diseases.

Transjugular liver biopsy effecting changes in clinical management

Although transjugular liver biopsies are frequently performed in patients with impaired blood coagulation, their impact on effecting changes in clinical management has not been assessed. We reviewed our experience with 43 consecutive transjugular liver biopsies performed over 3 years (1998-2000) at Westmead Hospital, Sydney, Australia. The technical success, procedural complication rates and subsequent management of these patients were ascertained from the medical case records. Forty-two (28 men) patients were studied. The indications for liver biopsy were as follows: assessment of hepatitis/cirrhosis status (n = 21), evaluation of liver dysfunction following bone marrow transplantation (n = 19) and miscellaneous (n = 2). All liver biopsies were performed with a Cook 20-G transjugular cutting needle device. Adequate histological samples were obtained in 42 (98%) of the 43 biopsies performed. The pre-biopsy diagnoses were confirmed by histology in 28 cases (65%). A change in clinical diagnosis was observed in 12 (28%) patients, and there were changes to subsequent management in all 12 patients. Four patients developed procedural complications, including small neck haematomas in two patients and a self-limiting biliary fistula in one. The only major complication was an extracapsular bleed from a hepatic laceration. This patient required emergency surgery but recovered. Transjugular liver biopsies can be effectively and safely performed in high-risk patients with impaired coagulation. They aid accurate histological appraisal of liver dysfunction in these patients and influence clinical decision-making.

Combined sonographic and fluoroscopic guidance during transjugular hepatic biopsies performed in children: a retrospective study of 74 biopsies

OBJECTIVE

Our aim was to evaluate the safety, effectiveness, and clinical impact of transjugular biopsies of the liver performed in children.

MATERIALS AND METHODS

We retrospectively reviewed 74 transjugular hepatic biopsies performed in 64 pediatric patients. The selection criteria for transjugular approach in these children included mainly coagulopathy, thrombocytopenia, or ascites. The last 37 biopsies in our series were performed with combined sonographic and fluoroscopic guidance, which improved visualization of the biopsy tract.

RESULTS

Adequate samples for histopathologic analysis were obtained in all except one case (98.6%). In most patients with fulminant hepatic failure, biopsy results allowed patients to be promptly listed for orthotopic liver transplantation; in patients with less severe hepatic failure, biopsy results helped guide medical management. In patients with liver transplants, the biopsy provided information on acute graft rejection; in patients who had undergone bone marrow transplantation, the biopsy helped to determine the status of graft-versus-host disease. One death occurred immediately after the procedure but at autopsy was deemed not to have been caused by the biopsy itself. Overall, procedural complications occurred in 8.1% of patients. Complications included neck hematomas, small subcapsular hematomas, subclavian artery puncture, and extravasation of contrast material into the retroperitoneum.

CONCLUSION

Transjugular hepatic biopsy is a relatively safe procedure that has considerable impact on patient treatment. The addition of sonographic guidance during the biopsy improves visualization, increases operator confidence, and allows the performance of biopsies in smaller patients and in children with reduced liver transplants.

Transjugular biopsy of the liver in pediatric and adult patients using an 18-gauge automated core biopsy needle: a retrospective review of 410 consecutive procedures

OBJECTIVE

The aim of our study was to evaluate the safety and efficacy of transjugular biopsy of the liver in a large population of patients using an 18-gauge automated core biopsy needle.

MATERIALS AND METHODS

A total of 371 patients underwent 410 attempted transjugular biopsies of the liver during an 80-month period. Data collected included the retrospective review of patients' computerized medical records, clinical charts, and nursing documents. Patient demographic data, indications for liver biopsy, laboratory findings of coagulation values, procedural data including number of needle passes performed, and histologic description of the specimens were noted. Indications varied and included traditional contraindications to the percutaneous approach such as coagulopathy (53%) and ascites (29%). In one patient, the hepatic veins could not be catheterized because of angulation with the inferior vena cava, and in one patient, biopsy was performed using the femoral route because of occlusion of the jugular vein. All patients were followed up for a minimum of 24 hr after the procedure to determine complications.

RESULTS

The mean number of needle passes per procedure was 3.4 (range, 0-18). Hepatic tissue was obtained in 409 procedures via the venous route (408 transjugular and one transfemoral), and a tissue diagnosis was achieved in 403 (98%). The six tissue samples were nondiagnostic because they were too small (n = 3) or too fragmented (n = 1) or because they did not contain hepatic tissue (n = 2). Ten complications (2.4%) occurred, including three intraperitoneal hemorrhages that resulted in one death.

CONCLUSION

Transjugular biopsy of the liver using an automatic core biopsy needle is safe and produces adequate tissue specimens in a high percentage of patients.

Vascular imaging and interventional procedures in hepatic cirrhosis

Changes in the vascularization of the cirrhotic liver are related to the progression of the disease. Knowledge of normal hepatic vascular anatomy and anatomic is essential for understanding the altered hepatic circulation seen in cirrhosis. We analyze the changes in liver perfusion with special interest in the anatomic features that are important in interventional procedures. The indications, technical notes, and complications of transjugular liver biopsy, transiugular intrahepatic portosystemic shunt (TIPS), and embolization of hepatocellular carcinoma, are reviewed.

Transjugular liver biopsy with an automated trucut-type needle: comparative study with percutaneous liver biopsy

OBJECTIVE

Transjugular liver biopsy using the suction method usually produces small specimens with excessive fragmentation, hence the diagnosis adequacy of specimens and the clinical impact of performing the biopsy have been questioned. An alternative biopsy needle, the Quick-Core needle system, which uses an automated trucut-type mechanism, has been shown to produce non-fragmented tissue specimens. The aim of the present study was to evaluate the safety, adequacy and clinical impact of the transjugular liver biopsy by comparing it with the standard percutaneous liver biopsy.

DESIGN

We recruited all patients who underwent liver biopsies by percutaneous or transjugular routes in the Department of Medicine, Princess Margaret Hospital, Hong Kong between January 1998 and December 1999.

METHOD

We recorded demographics and clinical features of patients, indications and complications, and the clinical impact of the liver biopsy procedure. All liver biopsy specimens were reviewed by the histopathologist, who was blinded to the approach of taking the biopsy. All variables between patients undergoing transjugular and percutaneous liver biopsies were compared.

RESULTS

During the study period, 50 percutaneous and 18 transjugular liver biopsies were performed. All transjugular liver biopsies were performed successfully with adequate tissue for diagnosis. Although specimens obtained by the transjugular technique tended to be shorter (10 mm v. 18 mm by the percutaneous approach, P < 0.001), the presence of fragmentation was similar to that in biopsies obtained by the percutaneous approach. Respectively, 100% and 98% of specimens obtained by the transjugular and percutaneous approaches were considered to be adequate for histological assessment. The clinical impact of transjugular and percutaneous liver procedures was comparable (89% v. 76%, P = 0.25).

CONCLUSION

Specimens obtained by a transjugular automated trucut needle are sufficient for histological assessment, and carry clinical impact in patient management.

Randomized controlled trial of aspiration needle versus automated biopsy device for transjugular liver biopsy

PURPOSE

The efficacy and safety of transjugular liver biopsy used to obtain liver specimens in patients with coagulation disorders have been widely proven. However, histopathologic examination is not always possible because of fragmented samples provided by the aspiration technique. Recently, an automated device with a Tru-Cut-type needle was designed. In this randomized controlled trial, the use of this new device is compared with the traditional method in terms of efficacy and safety.

METHOD

Fifty-six patients were included in the study; 28 were randomized to undergo the aspiration technique and 28 were randomized to undergo the automated biopsy technique.

RESULTS

Correct positioning of the device was achieved in 93% of patients undergoing the aspiration technique and 96% of patients undergoing the automated biopsy technique (P = NS). Mean duration of the procedure and total number of passes were significantly higher in the aspiration needle group than in the automated device group (22.6 min +/- 12.6 vs 15.5 min +/- 9.4; P = .03, and 3.3 min +/- 1.9 vs 1.5 min +/- 0.63; P < .001, respectively). The number of portal tracts was significantly higher in the automated device group (4.7 +/- 2.5 vs. 2.7 +/- 3.4; P < .05). Adequate specimens for histopathologic evaluation were obtained in 26 patients in the automated device group and 24 patients in the aspiration needle group (92.8% vs 85.7%; P = NS), but a definite histopathologic diagnosis was more frequently obtained with the automated biopsy device (68% vs 43%; P = .05). No significant differences were observed in complication rates (7.14% vs. 10.7%; P = NS).

CONCLUSION

The automated biopsy device for transjugular liver biopsy is more effective than an aspiration needle in obtaining good samples for a definite histologic diagnosis.

Transjugular liver biopsy with use of the shark jaw needle: diagnostic yield, complications, and cost-effectiveness

PURPOSE

Obtaining transjugular liver biopsy specimens with use of single-use needle systems is expensive, whereas biopsy specimens obtained with use of reusable needle systems are frequently associated with inadequate core specimens. The authors report their experience with the reusable Cook Shark Jaw biopsy needle, including diagnostic yield, complications, and cost-effectiveness.

MATERIALS AND METHODS

A retrospective audit was performed of a cohort of 134 patients who underwent 136 transjugular liver biopsies with use of a reusable 16-gauge Shark Jaw needle during a 30-month period. Specimen adequacy and complication rates were assessed and direct costs of expendable components calculated. Cost-effectiveness was expressed as cost-per-successful biopsy.

RESULTS

Biopsies were technically successful in 126 of 136 (93%) patients, with diagnostic histologic core specimens obtained in 124 of 126 (98%) patients, for an overall success rate of 91%. Complications included capsular penetration in six (4.4%) patients, cardiac arrhythmia in two (1.5%) patients, and puncture site hematoma or bleeding in 10 (7.4%) patients. Three tract embolizations were performed for capsular penetration. No instances of subcapsular hematoma, hemoperitoneum, or sepsis occurred, and no deaths were attributed to the procedure. The cost of expendable components totaled $103 per biopsy, corresponding to a cost-effectiveness of $113/successful biopsy.

CONCLUSION

Transjugular liver biopsy specimens obtained with use of the Shark Jaw needle have a diagnostic yield comparable to those obtained with use of single-use biopsy systems, at a substantially lower cost with no increase in serious complications.

Use of fibrin sealant as a hemostatic agent after liver biopsy in swine

PURPOSE

To determine whether fibrin sealant injected into the tract created by liver biopsy can be used to decrease postprocedural bleeding. An innovative delivery system was used to deploy the fibrin sealant.

MATERIALS AND METHODS

Fibrin sealant is a hemostatic agent consisting of a suspension of fibrinogen and thrombin. A delivery system was devised whereby fibrin sealant could be injected into the tract created by liver biopsy. Thirty swine were randomized into three groups: control (n = 10), heparin (n = 10), and warfarin (n = 10). Each swine underwent laparotomy and was randomized to undergo three to five open liver biopsies with either a 14-gauge cutting needle in conjunction with the fibrin sealant device or a standard 14-gauge cutting needle alone. Forty-seven biopsy procedures were performed with the device; 64 biopsy procedures were performed without the device. Immediate blood loss per biopsy (mL) was estimated based on the size of the blood stain on a sponge. Specimens were assessed for sample size.

RESULTS

Immediate blood loss with and without the device, respectively, was: control, 0.1 mL, 5.4 mL; heparin, 0 mL, 7 mL; warfarin, 0.1 mL, 9.3 mL. These differences were significant (P < .01) for each group of swine. In 43 of 47 biopsies (91%), the device functioned without difficulty. There was no difference in sample size when the device was used.

CONCLUSIONS

The fibrin sealant device is effective in reducing bleeding after open liver biopsy in anticoagulated and nonanticoagulated swine. The promising results suggest that a trial of percutaneous liver biopsy in swine should be considered.

Percutaneous transjugular kidney biopsy in swine with use of a side-cutting needle with a blunt-tipped stylet

PURPOSE

To evaluate a new 19-gauge blunt-tipped, side-cutting, single throw transjugular biopsy needle for transvenous kidney biopsies.

MATERIALS AND METHODS

Transjugular transvenous kidney biopsies were performed with a modified 70-cm biopsy needle utilizing fluoroscopic guidance in nine swine. Three tissue specimens were obtained with four biopsy device passes in five animals and three biopsy device passes in four animals. Renal arteriography and venography were performed immediately before and after renal biopsy. Five animals were killed immediately after biopsy. Four animals were allowed to recover and underwent arteriography and venography prior to being killed, which varied from 1 to 6 weeks. Gross and histologic examinations of the biopsied kidney were performed after euthanasia. A pathologist reviewed all biopsy specimens for quality based on the number of glomeruli present.

RESULTS

Results of immediate and delayed arteriography and venography were normal in all cases. Histologic evaluation of all biopsy specimens demonstrated a range of two to 13 glomeruli per sample (mean, 6.5), with successful acquisition of the cortex. In one animal killed immediately after biopsy, a small subcapsular hematoma was present.

CONCLUSION

The 19-gauge, side-cut biopsy needle with a blunt-tip stylet proved to be efficacious for obtaining renal cortical samples in right swine kidneys via a transjugular approach.

Use of fibrin sealant to reduce bleeding after needle liver biopsy in an anticoagulated canine model: work in progress

PURPOSE

Needle biopsy of the liver is a common diagnostic procedure. Although relatively safe, bleeding remains a potential complication and may occur more frequently in patients with coagulopathy. The purpose of this study was to evaluate the utility of a fibrin sealant in preventing bleeding after a 15-gauge needle biopsy of the liver in a canine model heparinized to simulate coagulopathy.

MATERIALS AND METHODS

Fibrin sealant was delivered to biopsy tract sites in eight dogs anticoagulated with heparin (activated clotting time 387 seconds +/- 94) using the same sheath system that was employed to obtain the biopsy specimen.

RESULTS

The results demonstrated complete hemostasis in the sealant-plugged tracts as compared to controls. Continuous bleeding was observed in none of the fibrin sealant-treated sites, compared with all of the control biopsy sites (P = .0078).

CONCLUSION

These results demonstrate the high degree of efficacy of fibrin sealant delivered through a sheath system in plugging liver biopsy tracts and eliminating bleeding in a severely coagulopathic animal model. This indicates that fibrin sealant use in cutting needle biopsies can reduce major and minor complications associated with the procedure.

Transvenous renal biopsy in an ex vivo swine kidney model: a comparison of five devices

PURPOSE

To compare the efficacy of end-cut and side-cut devices in transvenous renal biopsies of ex vivo swine kidneys and to examine the use of the swine kidney as an animal model in this setting.

MATERIALS AND METHODS

Biopsy specimens of ex vivo swine kidneys were obtained after selective renal vein cannulation with use of five separate biopsy devices (Quick-Core 16 gauge and 18 gauge, Colapinto 16 gauge, Mansfield biopsy forceps, Flexi-Temno 16 gauge). Biopsy specimens were defined as the material obtained from three separate passes at a given site, with 30 biopsy specimens obtained per device. Capsular perforation was examined for each pass. A blinded pathologist recorded the presence of tissue and the number of glomeruli present for each pass. A diagnostic biopsy was defined as six or more glomeruli obtained.

RESULTS

The median number of glomeruli obtained for each device per biopsy was Colapinto 0.0 (range, 0-13), Mansfield 0.0 (range, 0-19), Flexi-Temno 2.0 (range, 0-13), 18-gauge Quick-Core 8.5 (range, 0-30), and 16-gauge Quick-Core 16.0 (range, 0-52). The Quick-Core 16-gauge and 18-gauge devices obtained diagnostically adequate biopsy specimens 83% and 77% of the time, respectively, compared to 20% or less for the other devices.

CONCLUSION

The Quick-Core 16-gauge and 18-gauge side-cut biopsy devices are the most efficacious for obtaining diagnostic quality biopsy specimens in the ex vivo swine kidney model.

Transjugular liver biopsy: a review of 77 biopsies using a spring-propelled cutting needle (biopsy gun)

Seventy-seven transjugular liver biopsies were performed with a coaxial, spring-loaded, 18-gauge cutting needle, the Biopty gun (Bard Biopsy System, Covington, GA, USA) on consecutive patients between July 1993 and February 1995. Fifty men and 27 women were included in the study; the mean age was 45 years (range 15-69 years). The average number of punctures per patient was 5.2, with a range of 2-9, yielding an average of 4.8 samples per patient (range 1-7). The length of the samples varied from 10 to 22 mm with a constant diameter of 1 mm. The mean time required to complete the procedure was 48 min (43-52 min). Histological diagnoses were obtained in 74 of 77 patients (96%), with non-diagnostic specimens attributed to excessive fragmentation (3 cases). Complications occurred in 10 patients (puncture site hematoma, carotid artery puncture, abdominal pain, vasovagal reaction, hepatic capsule perforation, and hemobilia). The latter two complications were self-limited. In our experience this transjugular hepatic biopsy method is promising for performing biopsies in patients with chronic liver disease, due to its high success rate and low morbidity rate.