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CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting

Abstract

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Introduction

The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Standards of Practice Committee established a writing group, which was tasked with producing up-to-date recommendations for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature and are not intended to impose a standard of clinical patient care. Rather, the aim of this document is to recommend a reasonable approach to and best practices for performing percutaneous transhepatic cholangiography and biliary drainage and stenting.

A summary of key points can be found in Table 1.

Table 1 Summary of key points

Methods

The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of six clinicians with internationally recognised expertise on this topic. The writing group reviewed existing literature, performing a pragmatic evidence search using PubMed to search for relevant current and historic publications. The writing group formulated the recommendations in consensus during several meetings and through online digital communication.

Background

Percutaneous transhepatic cholangiography (PTC) is a radiological interventional procedure to visualise the biliary system. It is usually the first step in the procedure and is mostly followed by the placement of a drain, namely percutaneous transhepatic biliary drainage (PTBD), the placement of a stent, percutaneous transhepatic biliary stenting (PTBS) or other interventions. It provides an alternative to endoscopic retrograde cholangiography (ERC), which is often performed initially, although some authors also favour initial PTBD in certain situations, e.g. in central biliary tumours [1] In a number of anatomically challenging situations, however, PTC and PTBD are the first-choice approach [1,2,3,4,5,6].

Biliary obstruction can be an incidental finding ranging from subclinical disease with mild elevation of liver function tests, to severe cases with jaundice, hyperbilirubinemia, pain, pruritus and/or cholangitis. It is diagnosed by clinical features, laboratory parameters (including abnormal liver function tests and hyperbilirubinemia) and radiological findings on ultrasound (US), computed tomography (CT) or magnetic resonance imaging (MRI) (such as a dilated bile duct, intraductal biliary stones or tumours).

Table 2 gives an overview of causes of obstruction.

Table 2 Causes of obstruction

Biliary obstruction may be caused by strictures of the biliary tree itself, by endoluminal blockage or extraluminal compression or ingrowth. The causes can be broadly classified into two main groups: malignant and benign. Additionally, biliary obstruction may be due to postoperative complications. For treatment planning, it is crucial to investigate the cause of the obstruction.

Historically, PTBD was introduced in the early 1980s and has been used ever since. Early publications by Riemann and Faithfull demonstrated high technical success rates and low complication rates [7, 8]. They described the method as a temporary or permanent therapeutic option in patients who are not surgical candidates.

Biliopancreatic tumours and liver metastases are the main cause of malignant biliary obstruction [9]. This may be due to tumour infiltration, extrinsic compression and desmoplastic or inflammatory responses to tumours. Less frequent malignant underlying diseases are gallbladder cancer or metastatic lymph nodes in the hepatic hilum.

The most common benign cause of obstruction is intraductal cholangiolithiasis. A less frequent cause of biliary obstruction due to gallstones is Mirizzi syndrome. This refers to bile stones in the cystic duct or the infundibulum of the gallbladder causing upstream dilation of the intrahepatic bile ducts, with a normal common bile duct (CBD). Processes, such as primary sclerosing cholangitis, periportal fibrosis, IgG4-related cholangitis or pancreatitis, are less common. Chronic pancreatitis may also lead to biliary obstruction. Infectious causes may include secondary cholangitis, ascending cholangitis, HIV cholangiopathy, recurrent pyogenic cholangitis and parasitic infections.

While external compression is typically caused by malignancies, it may rarely be caused by portal cavernous transformation.

Iatrogenic duct injury following cholecystectomy, pancreaticoduodenectomy or orthotropic liver transplantation is a frequent benign cause of biliary obstruction and may occur as anastomotic strictures after bile duct injury repair, secondary to intraoperative injury or as a result of postoperative inflammatory responses [10, 11]. Other iatrogenic causes include partial hepatectomy, hepaticojejunostomy, chemotherapy and radiation therapy, either by causing direct damage to the bile ducts or by inducing periportal fibrosis or ischaemic cholangiopathy. Lastly, ischaemia may also lead to benign biliary strictures, which may occur after iatrogenic damage or after vasculitis.

Typical indications are summarised in Table 3.

Table 3 Summary of typical indications for PTBD and PTBS [38]

The only absolute contraindication is un-correctable coagulopathy [2, 6]. Relative contraindications include pregnancy, ascites, extensive hepatic cystic disease, visible infection at puncture side, low life expectancy ( <  30 days) and multifocal intrahepatic segmental stenosis.

Risk factors, which may increase bleeding risk, are coagulopathy, current antiplatelet use, central biliary access, use of larger needle sizes (e.g. 18G instead of 21G), multiple needle passes, non-dilated biliary system, liver cirrhosis, renal insufficiency and advanced age (Patel et al.). For more information on coagulation and periprocedural management of thrombotic and bleeding risk, the authors refer to the current documents by the SIR and CVIR [12, 13].

Patient Preparation

Pre-Procedural Imaging Evaluation

US evaluation of the liver is usually the primary imaging method due to availability, and patient safety due to excellent detectability of biliary obstruction and assessing the level of obstruction as well as the presence of biliary stone disease. MRI and CT in portal venous phase provide the best images for pre-interventional planning, as well as determining the underlying disease.

CT in portal venous phase is especially helpful to plan the optimal access route to the biliary system and to decide whether a left-sided, right-sided or bilateral approach is required. By the use of modern CT scanners and advanced post-processing software, even the optimal angle for fluoroscopy guidance can be assessed prior to the intervention. Therefore, while US is usually the primary technique for guiding, CT and MRI provide equal image information.

Pre-Treatment Preparation

No special preparation is necessary, except fasting of 3–6 h (depending on local protocol and type of sedation/anaesthesia) prior to intervention to prevent aspiration. Usual care for interventional procedures is required in terms of coagulation status (INR  <  1.5, platelet count  >  50.000/mm3). Concerning recommendations for periprocedural antibiotics, the authors refer to the recent SIR endorsed document by Chehab et al. [12], which recommends antibiotics for new placement and routine exchanges. I.V. antibiotics are recommended. (e.g. single-shot of 1 g Ceftriaxone, 1.5–3 g Ampicillin/Sulbactam). Regarding anticoagulation and antiplatelet drugs, the specific regimen for pre-interventional management depends on the type of anticoagulation used and a patient-based cardiovascular and procedural risk assessment (e.g. withdrawal aspirin or clopidogrel 5 days prior to intervention possible?). When ascites is present, pre-interventional puncture should be performed. If necessary, sedation and analgesia should be in reach and should be performed according to current guidelines [14].

Treatment

Prerequisites

Procedures must be performed by a qualified interventional radiologist (IR).

Imaging Equipment

The facility must at least offer a standard fluoroscopy c-arm. Advanced equipment with possibilities to perform a 3D cholangiogram or cone-beam CT might be useful in some cases. Depending on the manner of guiding the initial bile duct puncture, US equipment which allows for adequate bile duct visualisation should be available. Doppler US may additionally help to visualise flow to avoid vessel puncture. For cases involving non-dilated ducts, high-quality equipment is essential. Ideally, the used US probe (usually a curved 5 MHz transducer) has an optional needle guidance system. US can also be used to evaluate or exclude complications, such as subcapsular hematoma or free abdominal fluid.

Steps for Performing Treatment

Before starting the procedure, a safety checklist procedure is performed, for example using the CIRSE IR Patient Safety Checklist [15].

Patient Positioning

Patients are usually placed in supine position. If a rendezvous manoeuvre is intended (placement of a guidewire or drainage percutaneously through the bile ducts into the bowel, to be picked up endoscopically and used as guiding for endoscopic stent placement or stone removal), patients may be placed in prone position, which allows for right-sided PTBD access. PTC and PTBD must be performed under sterile conditions, which include sterile gown, gloves and mouth–nose protection for the physician and assisting nurse. After applying local antiseptic the patient is covered in sterile sheets, with an opening around skin markings. Standard sterile sheets used for femoral vascular access are appropriate.

Access

Depending on the dilatation of the ducts, different approaches can be used to puncture them. In moderate or non-dilated ducts, the use of micropuncture sets that include a dilatation system to upgrade to a 0.038 wire is recommended. In more dilated ducts, 18G Chiba or Trocar needles that support a 0.035/0.038 wire can be used. In most cases, standard vascular access sheaths (5–10 Fr) maintain access to the biliary system during the procedure. As an alternative, a 5–6 Fr radial artery sheath can be inserted over a 0.018 wire. (More details are given below under “procedural steps”.)

Bile Duct Navigation

In many cases standard angiographic wires and catheters can be used to pass stenosis and to navigate through the bile ducts towards the duodenum. In some cases, catheters with short angles or bends (e.g. the Bern, Berenstein or RIM catheter) can be useful. In cases with tight stenosis, smaller diameter catheters and wires (e.g. 0.018) can be of use.

Drainage Catheters

Biliary internal–external drains must be available, and mostly 8.5–10 Fr are used. In rare cases, bigger size drains (e.g. 12 Fr) can be of use. In rare cases if percutaneous cholangioscopy is intended (depending on the used material), the cutaneous-biliary fistula might require stepwise dilation of the tract up to 16 Fr, although most commonly used material will fit through 11 Fr fistulas. External drains should be available for cases in which passing a stenosis or obstruction is not possible. Standard pigtail drains (8,5/10 Fr) can be used in such cases; however, a variant with a smaller pigtail can be a good alternative in smaller, segmental ducts. In case of stent placement, to avoid entanglement of the locking wire to a stent strut, the use of non-locking drains or drains that allow removal of the locking wire is advised. All biliary drains can be connected to standard size draining bags.

Balloons

Dilatation of a malignant stricture can be performed before or after stenting, depending on the clinical case. Some interventionalists prefer to dilate the stricture before placement of metallic stents with an 8–10 mm balloon, so that better stent expansion is achieved. This includes the potential hazard of bleeding with thrombus formation and delay of bile drainage and bilirubin decrease; therefore, it is not commonly performed. Others prefer to expand the stent first and in case of inadequate expansion proceed to balloon dilatation with a similar-sized balloon immediately after stenting. And some others generally do not dilate and leave a 5 Fr safety catheter through the stent. If the stent did not fully expand after 2–3 days, balloon dilation can still be performed. Balloon insertion and retrieval should be always performed through a 6–7 Fr sheath depending on the balloon required, in order to protect the liver parenchyma, especially during removal of the de-inflated balloon. In most patients however, dilatation is not required, except in cases of very tight occlusions.

Stents

Many standard vascular self-expandable stents are approved for biliary intervention and can safely be used when stenting is required. In cases of bilateral parallel/Y-stenting (e.g. hilar cholangiocarcinoma), two identical stents should to be used to avoid compression of one stent due to differences in radial force. Usual stent size in the common bile duct is 10 mm; in the left/right hepatic duct sizes of 7–8 mm will often be sufficient. Specially designed stents with open cells can be used to perform y-stenting when only one-sided biliary access is available or possible. A second (balloon expandable) stent can easily be placed through the struts of the open cell stent. In some cases, covered stents might be used, if no intrahepatic branches are obstructed by the stent.

Procedural Steps in US Guidance

US is used to locate the bile duct and exclude ascites or colon interposition in the puncture area [16, 17]. The skin is marked using a standard marker pen. In some cases (especially when expecting a difficult puncture, e.g. in non-dilated ducts), multiple ducts can be selected as targets and the respective puncture sites on the skin should be marked. The US probe is placed in a sterile cover and the needle guidance is placed (if used).

When the procedure is performed under deep sedation, the puncture tract (including the liver capsule and skin) is anaesthetised using a local anaesthetic to minimise pain and movement of the patient when puncturing the liver and placing the access sheath. This is not necessary when performing the procedure under general anaesthesia; however, local anaesthetics might decrease post-procedural pain.

In many cases, an 18G vascular access needle can be used as a coaxial needle guide to minimise needle bending when puncturing biliary ducts. Using a 21–22G needle, the bile duct is punctured. Commonly a Chiba needle is used, which is a two-part hollow needle with a bevelled tip angled at 30 degrees, which allows optimal steering [18]. Correct puncture can be verified by aspiration of bile, or via injection of a small amount of CM. It is advised to use diluted CM (e.g. 50% CM/50% saline) and not to inject excessive CM during the procedure, as it can obscure visualisation of the catheters and wires and increases the risk of cholangitis. Injecting contrast may also result in injection of air microbubbles, which will distort the US image. Gentle insertion of the microwire can also verify correct puncture. If it is difficult to advance the microwire, the needle is likely not positioned in the duct and should be adjusted; if necessary, the use of CM may help to understand the anatomy of the biliary ducts to help guiding the wire to the desired position. Once the guide wire is positioned correctly, a sheath should be placed—pre-dilatation (depending on the size of the sheath) can sometimes be helpful, but is not regularly needed to place the sheath in the biliary system.

Aspirated bile should be assessed for its colour (turbidity), consistency and odour, and a sample should be collected for microbiological analysis in case of suspected cholangitis.

Procedural Steps Using Fluoroscopy

The patient is usually placed in supine position. Often an approach from the right lateral side of the patient is chosen, subcostal or intercostal in the midaxillary line. If an intercostal approach is considered, puncture should be at the superior aspect of the rib to avoid the intercostal artery, and extra local anaesthetics should be used as increased discomfort can be expected. The needle is advanced under fluoroscopy guidance up to the midclavicular line. Small amounts of CM can be injected (~0,1–0,2 ml) to see whether the biliary tree opacifies. Otherwise, the needle is pulled back until bile can be aspirated. After correct position of the needle is verified, a microwire is inserted. Once the microwire is advanced up to the stiffer part of the wire, a sheath (usually 4 Fr inner diameter) or radial sheath can be inserted. After placing the sheath, a small amount of CM (ideally diluted) can be injected to ensure intraductal position. Verifying the optimal needle position can also be done by, for example, at least two oblique views. The use of stiffer guide wires is advantageous to advance the sheath and in exchange manoeuvres, especially to avoid buckling. If a triaxial set is used, spinning rather than pushing may be helpful.

Procedural Steps in Biopsy

During the procedure, biopsy in unclear situations can be performed. This is usually done either by brush cytology or forceps biopsy [19, 20]. Due to the fact that the diagnostic yield of brush cytology is usually less than 60%, intraluminal forceps biopsy could be performed [21]. Nevertheless, their sensitivity is equal and a combination of both only modestly increases the sensitivity [22]. A sheath is advanced distally to the obstruction. The brush is than placed exactly at the location of the stenosis and the sheath is retracted, and the brush is moved several times within the stenosis. Cytology specimens are cropped from the brush on microscope slides and/or put in saline or a fixing solution according to instructions from the local cytology laboratory. Biopsy samples are usually placed in formalin or can be send as fresh samples in saline to the pathology lab. The biopsy canal may be plugged using coils or glue.

Procedural Steps in Drain Placement

Using standard vascular catheters and hydrophilic wires, the obstruction is passed, if possible, down to the duodenum (in normal anatomy).

A stiff guidewire is inserted into the distal duodenum (ligament of Treitz). Access route dilatation may be necessary; the degree of the dilatation depends on the size of required the drain. Finally, the internal/external drain is placed.

If passage of the stenosis is not possible, an external drain is placed. The type of drain (internal/external vs. external) should be well documented to avoid capping of an external drain. Drains can be fixed to the skin using stitches or a locking device.

The drain should not be removed until at least 10–14 days after placement, to allow the formation of a mature fistula around the drain in long-term PTDB. This will reduce abdominal biliary leaks after drain removal. In general it depends on the individual indication on how long a drain should be kept in place. To put a plug into the fistula after removal (e.g. using gelofoam) can be useful to avoid leakage.

Procedural Steps in Stent Placement

When combined in one procedure, the stent should be placed immediately prior to placement of the drain. In distal bile duct stenosis, the stent is advanced through the papilla into the duodenum and deployed over 1 cm. After that the stent system is retracted until the deployed part overlaps the papilla, then the stent deployed fully. To facilitate drain placement after stent deployment, the stent can be predilated with a balloon (e.g. 5 mm). Stent dilatation up to the full stent diameter is not necessary, as self-expandable metal stents will reach their size eventually, although this may take up to a few days. To avoid entanglement of the locking wire to a stent strut, non-locking drains or locking drains with the locking wire removed should be placed. Alternatively, a 5 Fr diagnostic catheter can be left in place.

After several days to a week, the drain can be removed if the patient is doing well and jaundice has resolved. In uncertain cases cholangiography may be indicated. Plug placement in the puncture tract can be considered.

Procedural Steps in Multiple Ducts

It can be necessary to place more than one drain, e.g. in hilar biliary stenosis or tumour compression, which does not allow passage of a drain into the bowel, when a single drain does not result in adequate lowering of serum bilirubin due to separation of sectors of the biliary tree. Procedural steps are the same as described above. To allow easier passage into the duodenum from the contralateral side, it is preferable to first place all required stiff wires before placing the drains as the last step of the procedure.

When multiple stents are placed in a Y-configuration (e.g. in hilar stenosis), both stents should be advanced over the respective wires to the desired location before deployment of any stent. Advancing a stent after deployment of a contralateral stent may result in movement of the first stent. Both stents should be deployed simultaneously, in a controlled manner.

Medication and Periprocedural Care

No standard periprocedural care is necessary and depends individually on the patient’s condition, complexity of the procedure and the use of anaesthesia.

Radiation Dose

Fluoroscopy guidance may result in a substantial amount of radiation dose to the patient, IR and assisting nurse. Thus, procedural radiation dose should be handled with care and radiation dose protection should always be in place. A reference level of 4300 cGyxcm2 for initial percutaneous biliary intervention and 1400 cGyxcm2 for follow-up interventions is recommended [23].

Post-Treatment Follow-up Care

Post-treatment care is straightforward and depends on the overall patient condition. Liver function and cholestasis parameters should be checked to assess treatment success. Imaging follow-up is not recommended on a standard basis, but depends on the clinical situation. If long-term or permanent drainage is required, drains should be exchanged every three months or on clinical indication.

Outcomes

Procedure-Specific Complications

The rate of complications in PTBD is relatively low, between 4 and 12%. A summary of complications can be found in Table 4. Rees et al. showed a strong correlation between the annual number of PTBD placements per centre and complication rates, with more experienced centres having the lowest reported complication rates [9]. Liu et al. showed that subsegmental entry was associated with a lower complication rate compared to a most possible peripheral entry level [24].

Table 4 Complications [9, 24,25,26,27,28,29,30,31]

Complications occur more frequently when bile ducts are not dilated. The most common complication is haemobilia, which occurs in up to 10% of all cases. Bleeding complications and biliovascular fistulas occur in up to 2.5% and 1.5% of cases. Infectious complications include sepsis, cholangitis and cholecystitis. Pneumothorax and peritonitis are rare complications. In long-term drainage drains can become obstructed, which may cause discomfort, leakage or cholangitis.

If venous or arterial bleeding occurs, the optimal treatment strategy depends on the extent of bleeding and the sources of the bleeding. Potential treatment consists of upsizing the catheter, checking positions of the side holes of the drain and flushing of the drain over several days. Transfemoral angiography may be necessary to locate the bleeding and treat with embolisation (e.g. coils or glue).

Technical and Clinical Success

The success rates of PTC and PTBD depend on the degree of dilatation, the experience of the interventionalist and clinical condition of the patient. In dilated biliary ducts, technical success (defined as diagnostic opacification of the ducts and/ or placement of an in-/external or external only drain) is reported at 90–100% [32,33,34].

Non-Dilated Ducts

In non-dilated ducts, technical success is somewhat lower compared to dilated ducts (80–97% [33, 35, 36]. A second attempt may improve success rates. Complication rates are similar to those in dilated bile ducts [35].

Liver Transplants

In transplanted livers technical success is also slightly lower (75–98%) compared to procedures in normal livers, but complication rates are comparable [37, 38].

Left-Side Versus Right-Side Puncture

In many observational series, a right-sided approach is commonly used with reported rates of 79–93% of cases. Left-sided approach is chosen in 4–11%, and in 3–12% of patients a double-sided approach is required [34, 36, 39].

Some comparative studies show a higher clinical success rate (bilirubin decrease) of left- versus right-sided puncture (81.5% vs. 68.6%) and a lower complication rate in left access (11.4% versus right 24%, p  <  0.001) [24]. Another study showed 100% success in both left and right approaches with a similar complication rate [16]. Some studies, however, found that a left-sided puncture was the only independent risk factor for arterial puncture. In one study, iatrogenic hepatic artery injury occurred only in a small number (1.9%) of cases and all cases were successfully treated by endovascular embolisation [25]. A recent study showed that a left-sided approach results in a higher Quality of Life score with less intercostal pain and breathing difficulties. Both approaches showed a technical success of 100% [40].

US Versus Fluoroscopy

There is no consensus in the literature whether to use US guidance or fluoroscopy. Fluoroscopy has been the traditional method of guiding the puncture of a bile duct. US guidance may ease this procedure, as bile ducts can be visualised directly. The applied technique depends on the experience of the user, as well as local preference.

Nennstiel et al. compared US and fluoroscopy guidance retrospectively [29, 41]. They found that fluoroscopy guidance was superior in the right-sided approach, while US guidance had a higher success rate in the left-sided approach. On the other hand, more major complications occurred in the group of fluoroscopy guidance. Wagner et al. concluded from an internal retrospective review and revision of the literature that the overall rate of severe complications with US guidance was significantly lower than with the use of fluoroscopy guidance (0% vs. 8%). Mortality was reduced as well (0% versus 1%) [17].

Stenting in Malignant Obstruction

In case of malignant obstruction, some advocate the use of covered stents in patients with a life expectancy > 3 months to reduce tumour ingrowth and prolong stent patency [42].

Randomised trials show varying results regarding covered versus non-covered stents in hilar or subhilar malignant obstruction. Krokidis et al. showed an improvement of patency in the covered stent group compared to bare metal stents, with stent dysfunction in 30% of bare metal stents compared to only 13% in covered stents and a nearly doubled median survival time of patients with covered stents [43]. Dhondt et al., however, showed a comparable technical and clinical success (100% and 82–84%) and an occlusion rate of 57% versus 54%, which was not significantly different [44]. Contrarily, Lee et al. observed a higher stent patency in bare stents compared to covered stent for malignant obstructive disease (413 versus 207 days, = 0.014) [45]. Therefore, the question about the clinical value of covered biliary stents remains to be answered.

Treatment of Benign Strictures

PBBD of benign strictures is a safe and effective option and is usually the primary option of choice. Balloon sizing, duration of inflation and drainage catheter size vary greatly. Generally, a 4–12 mm—depending on duct diameter—non-compliant balloon is inflated until the waist disappears, for a duration of several minutes [10, 11, 46]. Many authors apply repeat inflations during one PBBD session. More than half of patients will show clinical success after one session; however, some patients will require multiple PBBD sessions before PBBD treatment is complete [10, 11, 46, 47].

Reported technical success rates are very high at 97–100%. In difficult cases, cutting balloons might increase technical success with no significant increase in major complications [48]. Clinical success of PBBD in benign stenosis is high, with reported probability of patency of up to 0.95 at 1 year, up to 0.88 at 5 years and up to 0.72 at 10 years [10, 11, 46]. The odds of developing a clinically significant restenosis are slightly higher if the patient developed restenosis previously [46]. Long-term data, however, are still based on small patient groups.

The reported mortality rates are very low, approximately 0%. Morbidity rates vary between 2% and 13.9% [46, 49,50,51].

There is no difference in the rate of clinically significant restenosis after PBBD of biliary strictures at anastomotic and non-anastomotic sites [46]. A higher risk for the development of clinically relevant restenosis was linked to a higher number of strictures and number of required PBBD treatments, but not for stricture location [10].

When balloon dilatation fails, authors have reported the use of plastic stents, removable or biodegradable stents and placement of external drains until surgical treatment [52]. Several studies have investigated the use of removable stents, with improved 3-year outcomes compared to PBBD alone [47, 53]. However, long-term data are not yet available.

Conclusions

Percutaneous biliary intervention offers a wide variety of treatment options in benign and malignant disease, with very high success and low complication rates.

Percutaneous drainage and stenting can provide rapid biliary decompression and may offer beneficial long-term effects. The suggested improved patency of covered stents compared to bare metal stents in malignant stenosis has not been unequivocally proven. Percutaneous biliary balloon dilatation of benign strictures shows good long-term outcomes.

Abbreviations

CBD:

Common bile duct

CM:

Contrast media

CT:

Computed tomography

ERC:

Endoscopic retrograde cholangiography

MDCT:

Multidetector-row CT

MRCP:

Magnetic resonance cholangiopancreatography

MRI:

Magnetic resonance imaging

PTC:

Percutaneous transhepatic cholangiography

PTBD:

Percutaneous transhepatic biliary drainage

PTBB:

Percutaneous transhepatic biliary balloon dilation

PTBS:

Percutaneous transhepatic biliary stenting

US:

Ultrasound

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Definitions

Percutaneous transhepatic cholangiography (PTC)

PTC is a diagnostic procedure for imaging of the biliary system. It is mainly performed when cross-sectional imaging is not sufficient for diagnosis. Contrast media (CM), usually iodinated CM, is injected into a bile duct after percutaneous puncture of a peripheral duct. Diagnostic images are obtained by fluoroscopy in one or more projections. As magnetic resonance cholangiopancreatography (MRCP), US and CT are widely available, diagnostic PTC has become rare. It is now mostly performed as the first step in percutaneous transhepatic biliary drainage.

Percutaneous transhepatic biliary drainage (PTBD)

PTBD is a therapeutic procedure to provide internal or external drainage of the obstructed biliary system. It involves percutaneous puncture of a (peripheral) biliary radicle, followed by fluoroscopic or US guided wire and catheter placement. Often an attempt is made to advance a guide wire into the duodenum (or into the jejunum in surgically altered anatomy), in order to place an external-internal drain. PTBD can involve a right sided or a left sided approach or a combination of both, depending on best access route and underlying pathology.

Percutaneous biliary balloon dilatation (PBBD)

PBBD is a therapeutic procedure for the treatment of biliary strictures using intra ductal balloon dilatation. After percutaneous puncture, the stricture is passed with a guidewire. A balloon is inflated (usually for several minutes) to eliminate or improve the stricture. One PBBD session may require several balloon inflations. Usually a drainage catheter is placed after balloon dilatation at or just above the former stricture site.

Percutaneous transhepatic biliary stenting (PTBS)

This therapeutic procedure is used for temporary or permanent stenting of a biliary stricture in order to restore internal bile drainage. After percutaneous puncture, the stricture is passed with a guidewire. A plastic or metal (un)covered stent is then placed at the site of the stricture.

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Das, M., van der Leij, C., Katoh, M. et al. CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting. Cardiovasc Intervent Radiol (2021). https://doi.org/10.1007/s00270-021-02903-4

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Keywords

  • Percutaneous transhepatic cholangiography
  • Percutaneous transhepatic biliary drainage
  • Pancreatic neoplasm
  • Bile duct