Transfemoral Transcaval Core-Needle Liver Biopsy: An Alternative to Transjugular Liver Biopsy

Transfemoral-Transcaval Liver Biopsy (TFTC) and Transjugular Liver Biopsy (TJLB) in Patients with Fontan-Associated Liver Disease (FALD)

PURPOSE

To describe our experience in performing transfemoral-transcaval liver biopsy (TFTC) and transjugular liver biopsy (TJLB) in patients with Fontan-associated liver disease (FALD).

METHODS

A single-center, retrospective review of 23 TFTC and seven TJLB performed between August 2011 and May 2023 on patients who previously underwent the Fontan procedure (median age 23.1 years, ranging 11-43 years, 48% female). Patient demographics, laboratory values, pathology, radiology, and cardiology reports were reviewed. Liver explants were correlated with histopathological evaluation to determine sampling accuracy when available.

RESULTS

All biopsies achieved technical success (accurate targeting and safe tissue sample extraction) and histopathological success (yielding sufficient tissue for accurate diagnosis). Liver biopsies were performed during simultaneous cardiac catheterization in 28 of 30 (93%) procedures. There was no statistically significant change in hemoglobin, hematocrit, platelet count post-procedure, and fluoroscopy times. There was one major complication within the TJLB group and one minor complication within the TFTC group.

CONCLUSION

Transvenous liver biopsies, whether via transfemoral or transjugular route, may be safely performed in FALD patients while yielding samples with technical and histopathological success. The transfemoral approach, which is our preferred method; its compatibility with simultaneous cardiac catheterization and its potentially increased safety profile stemming from the avoidance of transversing the Fontan shunt-makes it a particular advantageous option in the management of FALD.

Successful diagnosis of a localized liver tumor via transjugular liver biopsy after ascites hampered a percutaneous approach

Liver biopsy is a crucial diagnostic procedure for liver-related conditions. However, it is challenging to use in cases with substantial ascites or coagulopathy. Transjugular liver biopsy has been introduced as an alternative method to overcome these limitations. Although transjugular liver biopsy is commonly used for diffuse liver diseases, its application to localized tumors has been limited. We report the case of a 66-year-old male initially diagnosed with unresectable pancreatic carcinoma, who later developed liver metastasis, peritoneal dissemination, and ascites. Treatment planning required tumor re-evaluation, but percutaneous liver biopsy was not viable because of the rapid accumulation of ascites and its presence on the liver surface. However, transjugular liver biopsy was a suitable alternative, given the proximity of the tumor to the right hepatic vein. The procedure, performed under fluoroscopic and ultrasound guidance, successfully obtained 4 specimens that were promptly diagnosed as liver metastases originating from pancreatic cancer. This case underscored the effectiveness of transjugular liver biopsy in situations where percutaneous biopsy is challenging because of conditions such as ascites. The combination of ultrasound guidance and rapid specimen assessment by pathology technicians can enhance diagnostic success rates. Transjugular liver biopsy is a valuable diagnostic tool in scenarios where percutaneous access poses significant difficulties.

The Use of the Transfemoral Transcaval Liver Biopsy Technique for Biopsies of Hepatic Masses

The purpose of this study was to investigate the safety and effectiveness of the transfemoral transcaval (TFTC) liver biopsy technique in patients with hepatic masses with relative contraindications to percutaneous biopsy and/or mass location abutting the inferior vena cava. The medical records of 16 patients (56% men; age range, 21-88 years) who underwent TFTC biopsy of hepatic masses (ranging in diameter from 2.1 to 13.2 cm) from September 2015 to August 2021 were reviewed. Histopathologic diagnoses were made in 15 of 17 (88%) procedures. Two adverse events were noted: worsened preexisting hemobilia requiring embolization in 1 patient, and a decrease in hematocrit level in another patient, requiring only observation. In conclusion, this report showed that the TFTC technique is a relatively safe and effective method for sampling hepatic masses in select cases.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

Transjugular Liver Biopsy

Transjugular liver biopsy (TJLB) was first performed in 1970 and has since become a standard procedure in interventional radiology practices. TJLB can be used when a percutaneous liver biopsy is contraindicated, such as patients with ascites, coagulopathy, congenital clotting disorders or for patients undergoing concurrent evaluation for portal hypertension. While TJLB specimens tend to be smaller with less complete portal triads numerous studies have shown the samples to be adequate for diagnosis and staging. This article will review what the interventional radiologist needs to know about TJLB including indications/work-up, technical details, tips and tricks, and complications.

Outcomes of transjugular liver biopsies for liver transplant recipients with bicaval and piggyback hepatic vein anastomoses

BACKGROUND

Liver transplant hepatic venous anastomoses are usually created using "bicaval" or "piggyback" techniques, which may result in unfavorable angulation between the inferior vena cava and hepatic veins, and makes hepatic vein catheterization and tissue sampling during transjugular liver biopsy (TLB) technically challenging.

PURPOSE

To compare the technical successes and complications of TLBs for recipients of liver transplants with bicaval and piggyback hepatic vein anastomoses.

MATERIAL AND METHODS

Information on type of hepatic vein surgical anastomosis was available for 190 adult patients in whom 306 consecutive TLBs were performed during 2009-2017: 158 with bicaval and 148 with piggyback anastomoses. The primary outcome of procedural success was defined as obtaining a tissue sample sufficient to make a pathologic diagnosis.

RESULTS

A technical success rate of 97% with adequate liver tissue for diagnosis was similar between the anastomotic groups (P = 0.50). TLB was unsuccessful in 3% of patients with piggyback anastomoses due to unfavorable hepatic venous anatomy whereas biopsy was successful in all patients with bicaval anastomoses (P = 0.02). Fluoroscopy times were not significantly different (12.1 vs. 13.9 min, P = 0.08). Rates of major complication were similar between the two groups (3% vs. 3%, P > 0.99).

CONCLUSION

TLB is safe and effective for liver transplant patients regardless of the type of hepatic vein anastomosis. While failure to catheterize or advance the stiffened biopsy cannula into the hepatic vein is more likely to occur in patients with piggyback anastomoses, this is a rare occurrence.

Detection of adenovirus hepatitis and acute liver failure in allogeneic hematopoietic stem cell transplant patients

Human adenovirus (HAdV) is an important cause of the common cold and epidemic keratoconjunctivitis in immunocompetent individuals. In immunocompromised patients, HAdV can sometimes cause severe infection such as cystitis, gastroenteritis, pneumonia, encephalitis, hepatitis, or disseminated disease, resulting in significant morbidity and also mortality. In particular, severe cases have been reported in patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Indeed HAdV has been recognized as a pathogen that requires careful monitoring in allo-HSCT patients. While HAdV hepatitis leading to severe acute liver failure is rare, such liver failure progresses rapidly and is often fatal. Unfortunately, HAdV hepatitis has few characteristic symptoms and physical findings, which makes it difficult to promptly confirm and start treatment. We report here four cases of HAdV hepatitis after allo-HSCT and their autopsy findings.

Transjugular versus Transfemoral Transcaval Liver Biopsy: A Single-Center Experience in 500 Cases

PURPOSE

To compare the safety and efficacy of transfemoral transcaval liver biopsies (TFTC) with that of transjugular liver biopsies (TJLB) at a single tertiary-care institution.

MATERIALS AND METHODS

A retrospective review was performed of 500 consecutive transvenous liver biopsies between December 2010 and December 2018. The cases included 286 TFTC patients at a median age of 54 years old (interquartile range [IQR], 42-63 years of age), 37.4% were female; and 214 TJLB patients at a median age of 55 years old (IQR, 46-61 years of age), 45.4% female. Patient demographic and laboratory data and technical and histopathological success, fluoroscopy times, and complications were recorded. Comparative statistical analyses were performed using a 2-sample test or a Wilcoxon ranked sum test for continuous variables and a chi-square test or Fisher exact test for categorical variables when appropriate.

RESULTS

TFTC and TJLB data are presented as: technical success rates of 99.3% (283 of 286) and 100% (214 of 214), respectively; histopathologic success rates of 96.5% (275 of 285) and 95.8% (205 of 214), respectively; and major complication rates of 1.4% (4 of 284) and 5.6% (12 of 214), respectively (P = .009). There were no hepatic injuries in the TFTC group, whereas the TJLB group included 6 significant hepatic injuries requiring intervention. Median fluoroscopic times were 5.5 minutes (IQR, 3.9-8.6 minutes) for TFTC and 8.1 minutes (IQR, 5.2-13.1) for TJLB (P < .001).

CONCLUSIONS

In this single-institution study, TFTC was associated with a lower major complication rate and lower fluoroscopy times than conventional TJLB with similar technical and histopathologic successes.

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.

A simple insertion technique to reduce the bending of thinbevel-point needles

Objective: Needle insertion is a common component of most diagnostic and therapeutic interventions. Needles with asymmetrically sharpened points such as the bevel point are ubiquitous. Their insertion path is typically curved due to the rudder effect at the point. However, the common planned path is straight, leading to targeting errors. We present a simple technique that may substantially reduce these errors. The method was inspired by practical experience, conceived mathematically, and refined experimentally. Methods: Targeting errors are reduced by flipping the bevel on the opposite side (rotating the needle 180° about its axis), at a certain depth during insertion. The ratio of the flip depth to the full depth of insertion is defined as the flip depth ratio (FDR). Based on a model, FDR is constant 0.3. Results: Experimentally, the ratio depends on the needle diameter, 0.35 for 20Ga and 0.45 for 18Ga needles. Thinner needles should be flipped a little shallower, but never less than 0.3. Conclusion: Practically, a physician may expect to reduce ∼80% of needle deflection errors by simply flipping the needle. The technique may be used by hand or with guidance devices.

A South Indian Cadaveric Study About the Relationship of Hepatic Segment of Inferior Vena Cava with the Liver

INTRODUCTION

Inferior Vena Cava (IVC) is the largest vein of the body. It runs vertically upwards in the abdomen, behind the liver. Its course is very constant in relation to liver. However, the amount of liver parenchyma related to it can vary from person to person. The data regarding its course and relations may be very useful to radiologists and surgeons during surgical treatment procedures for Budd-Chiari syndrome, liver carcinoma, liver transplant, venous cannulations and many other clinical procedures.

AIM

Aim of this study was to document the incidence of straight and curved course of IVC in relation to liver and also to note the pattern in which the liver tissue was related to the IVC.

MATERIALS AND METHODS

In the current study, 95 adult cadaveric livers were observed; specifically to study the course/direction of the hepatic segment of IVC in relation to the liver. The extent of liver tissue related to various aspects of IVC was also studied. The course of the IVC was classified as straight and curved; and the relationship of liver parenchyma to the IVC was classified into 6 categories. The data was expressed as percentage incidence.

RESULTS

In 78.94% cases, the IVC had a straight course in relation to the liver; whereas in 21.06% cases, it had a left sided curve (concavity of the curve towards the caudate lobe) in its course. In 6.31% cases, IVC travelled in a tunnel, being encircled by the liver parenchyma all around; in 36.84% cases, it was covered by liver parenchyma on front and sides so that only posterior surface of IVC was visible; in 3.15% cases it was covered by liver tissue on front, sides and also partly on posterior aspect; in 50.52% of cases, its anterior surface, sides and left edge of the posterior surface was covered by liver tissue; and in 3.15% cases it was covered only from the front by the liver tissue.

CONCLUSION

The data being reported here might be useful for surgeons while planning and executing various hepatic surgeries and also to the radiologists in planning and performing venous cannulation and therapeutic procedures. Since in many livers, the curvature of IVC was associated with enlarged caudate lobe, the curved IVC could hint about the increase in the volume of caudate lobe or liver itself.