Transjugular Liver Biopsy

Sebastian Kos, Deniz Bilecen, Augustinus Ludwig Jacob and Markus H. Heim

Clinical Relevance

Despite tremendous achievements in diagnostic imaging, laboratory studies, and clinical medicine, it is still valuable and often mandatory to acquire liver tissue samples for further histopathologic characterization of infectious, metabolic, and neoplastic diseases and/or their course.

Historically, Paul Ehrlich, a German pioneer of immunology, was the first to perform a percutaneous liver biopsy. In 1883, he determined the hepatic glycogen content in a diabetic patient.¹ In the following years, Lucatello applied the technique on a liver abscess (1895). Schüpfer et al. had already documented its potential in the diagnosis of chronic cirrhotic liver disease in a series of rat experiments and clinical studies. After Menghini propagated the “1-second needle biopsy of the liver” 50 years later, this procedure was broadly implemented in the management of chronic and acute hepatic diseases.²

Since the early days when blind biopsies were performed, a tremendous evolution of the biopsy procedure has taken place. Approaches, materials used (true cutting needles, fine-needle aspiration), and guided imaging techniques (e.g., fluoroscopy, sonography, computed tomography) have been improved, applied, and evaluated.

Meanwhile, percutaneous liver biopsy has been well proven to allow fast, safe, and adequate tissue sampling. It therefore has become the gold standard to obtain liver specimens. However, because it by definition penetrates the hepatic capsule, there is a significant risk for intra- and perihepatic hematoma and consequent relevant blood loss. This technique must not be used in patients with a known or suspected bleeding diathesis or those receiving oral anticoagulation. Further factors like an uncooperative patient, severe obesity, or high-volume ascites have been shown to increase the complication rate and may lead to puncture failure.

Therefore, alternative approaches (laparoscopic, transfemoral, transjugular) were established, enabling hepatic tissue sampling after failure of, or in the presence of contraindications for, the biopsy procedure.³ Given their higher mortality and morbidity, the use of laparoscopic biopsies is reduced to special cases, such as when an abdominal operation under general anesthesia is mandatory otherwise.³

As a pioneer, Dotter was the first to biopsy dog livers using a transvenous jugular approach in 1964.⁴ Weiner and Hanaffe used the same access to catheterize the hepatic veins in 1967, and in 1970 published their initial experience with transjugular hepatic biopsy in a series of humans.^5,6 By 1973, Rosch had already performed the technique on 44 patients, showing the need for the procedure.⁷ Unlike percutaneous access, it approaches the liver through the right jugular vein, through the vena cava, and most often the right hepatic vein. The biopsy is then performed directed away from major vessels into the parenchyma (inside-out). The capsule is not injured, minimizing the risk of intra- or perihepatic hematoma. Blood leakage into the biopsy channel immediately drains into the access vein, thereby avoiding significant extravascular blood loss and hemodynamic alterations.

Today the transjugular liver biopsy is well accepted and broadly established as the first-line backup for the percutaneous approach.⁸ In the hands of an experienced interventional radiologist, it is safer than the latter and well tolerated. Since many patients with liver disease consequently suffer from coagulopathy and/or ascites, there is huge potential for the technique.

Optional concomitant measurement of the hepatic venous pressure gradient (HVPG) is calculated as the difference between wedged (WHVP, an estimate of portal venous pressure) and free hepatic venous pressure (FHVP). It was shown that the HVPG provides relevant information to assess the risk of esophageal varix bleeding in patients with known portal hypertension. Furthermore, it may help document the efficacy of drug treatment in those patients by its changes over time.⁹ The risk of variceal bleeding is zero with HVPG lower than 12 mmHg, whereas an HVPG of more than 20 mmHg in cirrhotic patients is predictive of early rebleeding and death.⁹