Fig. 3. 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) Although the guidedwire was able to pass through the stricture site, the 8-Fr metal stent delivery system could not be passed during endoscopy due to tightness. (C) An ultrasound-guided puncture in the right intrahepatic duct was successful. (D) Two self-expandable metal stents (T-type) were inserted successfully via the previous percutaneous tract.