Fig. 2. Cholangiograms demonstrating successful palliation using the percutaneous method after failed endoscopy. (A) Magnetic resonance cholangiography demonstrated a Bismuth type IV hilar malignancy, with dilation of both intrahepatic ducts. (B) The guidewire was not able to pass through the stricture site during endoscopy due to tightness. (C) An ultrasound-guided puncture at both intrahepatic ducts was successful. (D) Two self-expandable metal stents (X-type) were inserted successfully via the previous percutaneous tracts.