Liver Biopsy–Transjugular

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Abbreviations

CPT

complete portal tracts

PLB

percutaneous liver biopsy

TJLB

transjugular liver biopsy.

Introduction

First described by von Frerichs in 1884,1 liver biopsy remains a cornerstone for diagnosing liver disease. Transjugular liver biopsy (TJLB) was introduced about 80 years later2 and found its way into clinical practice in 1967. In the beginning, Hanafee et al. used liver vein catheterization for biliary tract cholangiography,3 and later they also used it for liver biopsy.4

This transjugular approach was also introduced for kidney biopsy in the 1990s,5 but it has not gained widespread popularity since its introduction nearly 20 years ago.

Liver biopsy is the gold standard for histological diagnosis and assessment of the severity of liver disease.6

The advantages (pros) and disadvantages (cons) of transjugular and percutaneous (ultrasound guided/aimed) liver biopsy (PLB) are shown in Table 1. For the indications and contraindications of TJLB, see Table 2.

Table 1.

Advantages and Disadvantages of Transjugular and Percutaneous (ultrasound guided/aimed) Liver Biopsy

Pros of TJLB	Cons of TJLB	Pros of PLB	Cons of PLB
Feasible in patients with acute liver failure or with congenital clotting disorder7	Available only in large volume center	Gold standard for histological diagnosis and assessment of the severity of the liver disease6	Clotting disorders
Can be used in combination with other interventions required in cirrhotic patients (hepatic venous pressure gradient measurement, right heart catheter)	Price	Widely available, easy method	More complications than TJLB10
Fewer overall complication in TJLB (7%‐20%8, 9, 10 versus 38% in PLB10)	Less portal fields in a single specimen		More than one pass to obtain sufficient tissue might increase complications6
Better tolerability11 and less pain because Glisson capsula is not penetrated10			Use of more analgetic postbiopsy10

Table 2.

Indications and Contraindications for TJLB.

Indication TJLB	Contraindication TJLB
Performed when percutaneous approach is contraindicated (coagulopathy, ascites, and morbid obesity 12, 13, 14	No specific contraindication 15 Access to the right jugular internal vein not possible

TJLB: Quality

Specimens taken should be 20‐ to 25‐mm long. The amount of complete portal tracts (CPT) necessary to obtain a diagnosis ranges from 4 (to rule out graft rejection after liver transplantation16) to 11 (viral or nonalcoholic steatohepatitis17). However, even when using percutaneous liver biopsy, these numbers cannot be obtained in a substantial proportion of patients. In a previous study, the proportion of patients in which a specimen with ≥ 10 portal tracts could be obtained by percutaneous liver biopsy using a 17G Menghini needle was only 42%.18

The classic definition of CPT is having the full circumference visible, or at least three‐quarters of the circumference, and three luminal structures. Furthermore, a CPT must include at least one hepatic artery, one portal vein, and one interlobular bile duct.19

Procopet et al. reported in his studies that the liver biopsy (LB) sample length and the number of total portal tracts between PLB and TJLB were similar. This indicated that there should be no difference in the quality of LB between the two techniques10, 20, 21 Currently, two systems are used for transjugular liver biopsy: The specimens taken during TJLB with the Menghini technique are more often smaller, more fragmented compared with PLB.6 This difference in quality is often related to the circumstance that TJLB is frequently performed in patients with cirrhosis. However, as stated in the review by Kalambokis et al., the development of thinner Tru‐Cut needles has improved the quality of liver sample taken by TJLB (longer and less‐fragmented samples) and could result in fewer complications than the Menghini technique because it is easier to control the depth of puncture.8

At the Royal Free Hospital in London, United Kingdom, Cholongitas and Burroughs in 326 consecutive TJLB obtained a mean sample length of 22 ± 7 mm and a CPT number of 8.7 ± 5.0 using Tru‐Cut needles with three passes as standard.22 Unpublished data of TJLB of our patient cohort only show a median of five portal tracts in patients with cirrhosis and nine in patients without cirrhosis compared to six and 14 in PLB within the last year, respectively.

TJLB: Complications

Good biopsy samples can be obtained on TJLB by multiple passes without increasing the risk of complications6 because regularly Glisson's capsule is not penetrated.20 Kalambokis et al. differentiate between minor and major complications, which appears respectively in 6.6% and 0.6% of TJLB.8

Minor complications include abdominal pain, supraventricular arrhythmias, and complications in the neck such as pain, bleeding, and hematoma. Complications such as neck pain, hematoma, and carotid artery puncture are significant decreased when coupled with ultrasound guidance.8

The major complication are further divided in nonliver‐related (arteriovenous fistula formation, pneumothorax, and vena cava perforation) and liver‐related (hepatic hematoma and intraperitoneal hemorrhage as result of capsule perforation).9

In case of bleeding (intrahepatic hemorrhage from bleeding artery, pseudoaneurysma of a hepatic arterial branch, and subcapsular hematoma from an arterioportal fistula), the treatment of choice is angiography with coil embolization of the injured vessel.23

TJLB: Surveillance

In many centers, TJLB is performed in inpatients and outpatients. There are no specific guidelines for postinterventional follow‐up. However patients usually stay overnight for safety (hemoglobin control, x‐ray posttransjugular access) or economical reasons.

TJLB: Sedation

Sedation is not used routinely during TJLB because TJLB is usually performed in combination with hepatic venous pressure gradient measurements, and sedation may influence portal pressure.24, 25 However Steinlauf et al. demonstrated that Midazolam may be used at a dose of 0.02 mg/kg without significantly affecting portal pressure.26

Conclusion

TJLB represents a generally safe alternative to PLB for evaluation of the severity of liver disease in patients ineligible for percutaneous liver biopsy. Tru‐cut techniques may overcome the drawback of less portal tracts of the transjugular route, especially in a cirrhotic cohort.