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Jeffrey I. Mondschein, MD

Hepatobiliary and portal Venous 
interVentions

  1.  What are the indications for percutaneous transhepatic biliary drainage?

Percutaneous biliary drainage is indicated for the treatment of cholangitis or pruritus related to hyperbilirubinemia in 

the setting of benign or malignant obstructive biliary disease. Biliary drainage may also be performed in the setting of 

a traumatic bile leak to help divert bile and promote healing of the injured duct. Generally, percutaneous drainage is 

indicated only if access of the ducts via endoscopic retrograde cholangiopancreatography is impossible.

  2.  List the causes of benign and malignant biliary obstruction.

•

  Common benign causes include bile duct calculi (

Fig. 34-1

), benign strictures, pancreatitis, and sclerosing cholangitis 

(

Fig. 34-2

).

•

  Less common benign causes include Caroli disease, Mirizzi syndrome, and parasites.

•

  Common malignant causes include pancreatic cancer (

Fig. 34-3

), metastatic disease, and cholangiocarcinoma.

•

  Less common malignant causes include gallbladder carcinoma and ampullary tumors.

  3.  What is the most commonly encountered biliary ductal anatomy?

The main left bile duct is formed by the union of two horizontally oriented superior and inferior segmental ducts. Right lobe 

ductal anatomy is more complex and variable. The posterior-inferior and posterior-superior portions of the right hepatic lobe 

are drained by the right posterior ducts (also known as the right dorsal caudal ducts). The anterior-inferior and anterior-

superior portions of the right hepatic lobe are drained by the right anterior ducts (also known as the right ventral cranial 

ducts). The main right hepatic duct is formed by the union 

of the right posterior and anterior ducts. The confluence of 

right and left ducts forms the common hepatic duct, which 

is joined by the cystic duct (from the gallbladder) to form 

the common bile duct. The most common biliary ductal 

anatomy (approximately 60% of the population) consists of 

a right posterior segment duct that joins the right anterior 

segment duct to form the main right duct (

Fig. 34-4

).

4.   Describe the basic steps required 

to perform diagnostic percutaneous 

transhepatic cholangiography.

 

 Under fluoroscopic guidance, a 21G or 22G needle is 

passed into the liver through an inferior intercostal 

or subcostal space at the level of the right mid-

axillary line. It is important to verify that the needle 

does not pass through the pleural space. The needle 

is withdrawn during injection of contrast agent in 

an effort to opacify a bile duct that may have been 

traversed as a result of the needle pass. When a 

bile duct is identified, injection of contrast agent 

is continued, and the biliary tree is opacified. A 

diagnostic cholangiogram is performed with spot 

images obtained in anteroposterior and multiple 

bilateral oblique projections.

Key Points: Biliary Drainage

1.  An obstructed, infected biliary system constitutes a medical emergency.

2.  Complications from percutaneous biliary drainage can be life-threatening. An endoscopic approach is preferred 

when possible.

Figure 34-1. 

Percutaneous transhepatic cholangiogram performed to 

relieve biliary obstruction shows multiple common bile duct stones, seen 

as filling defects among the injected intrabiliary contrast material.

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  5.  Describe the basic steps required to perform percutaneous transhepatic biliary 

drainage.

If indicated by the diagnostic percutaneous transhepatic cholangiogram and clinical symptoms, a wire can be placed 

via the accessing needle into the biliary tree, followed by tract dilation and biliary drainage catheter placement. This is 

called the “one-stick” method. If the initial puncture was directed into a central duct, a “two-stick” technique may be 

used. Central duct punctures are not ideal because the risk of injuring a major hepatic vessel is significant. A second 

needle may be placed into an appropriate duct that subsequently is dilated and used for access. The ideal access site is 

an opacified peripheral duct that can be easily accessed under fluoroscopic guidance. Aside from a peripheral location, 

the duct’s path should course through an angle that is gentle enough to allow a catheter to be advanced into the small 

bowel without extreme angulation. After the second access is obtained, the first needle can be removed. If left-sided 

biliary drainage is being performed, the needle is passed into the liver from a left subxiphoid approach.

A

B

RASD

RPSD

LHD

Figure 34-4. 

A, The most common biliary ductal anatomy consists of a right posterior segment duct (RPSD) that joins the right anterior 

segment duct (RASD) to form the main right duct. LHD = left hepatic duct. 

B, Variant insertions of the RPSD.

Figure 34-2. 

Percutaneous transhepatic cholangiogram shows 

“beading” of intrahepatic biliary ducts, with segments of duct dilation 

proximal to regions of duct stricture. This stricture-dilation pattern is 

common in sclerosing cholangitis.

Figure 34-3. 

Percutaneous transhepatic cholangiogram shows 

intrahepatic biliary dilation secondary to malignant stricture of the 

common bile duct. This condition was due to carcinoma of the 

pancreatic head.

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  6.  What is the difference between an external biliary drainage catheter and an internal/

external biliary drainage catheter?

External drains end internally within the bile ducts above the site of obstruction. The obstructed biliary tree is 

decompressed by draining the bile externally into a drainage bag. Internal/external drains cross the site of obstruction 

and end within the small bowel. Bile may drain internally from the biliary tree through side-holes in the catheter into the 

small bowel, and the catheter may be capped externally. Internal/external drainage catheters are placed whenever it is 

possible to cross the site of obstruction because this type of drainage is more physiologic. Internal drainage prevents 

loss of bile salts and electrolytes and allows the bile to aid in fat metabolism within the bowel. It is important to monitor 

the volume status and electrolytes of patients draining bile externally. These patients can lose a large volume of fluids 

rich in electrolytes.

  7.  When should an internal/external drain be capped? When should this drain be 

uncapped?

After a de novo biliary drainage, catheters are almost always attached to a bag for gravity drainage for a specified time. 

External drainage helps to decompress the biliary system. A pressurized system may promote bacterial translocation 

into the hepatic vasculature, resulting in sepsis. Obstructed systems are likely to be pressurized, and this is exacerbated 

by the contrast agent injected into the ducts during the procedure. Pruritus often resolves faster if drainage is 

maximized. In the setting of a malignant obstruction, administration of chemotherapeutic agents may be delayed if 

the serum bilirubin level is excessively elevated. In certain situations, internal and external drainage may accelerate 

normalization of the serum bilirubin level and allow for the subsequent administration of chemotherapeutic agents.

Patients with drains placed for external drainage can lose a significant amount of fluids and electrolytes. Tubes are 

commonly capped when possible to allow more physiologic drainage of bile. Usually this occurs when concerns over 

infection have subsided, and pruritus has resolved. If chemotherapy is planned, tube capping may be delayed until the 

serum bilirubin level is within an acceptable range.

After a tube has been capped, it should be uncapped because of infectious concerns (fever, bacteremia, sepsis, elevated 

white blood count), leakage of bile around the catheter, pain, and increasing bilirubin or other liver enzyme levels. After 

the tube is uncapped, additional tests may be indicated, such as a tube check to determine whether the tube is clogged 

or malpositioned.

  8.  A patient begins to leak bile around an indwelling biliary drain. Why does this 

happen? What can be done?

Biliary drains require considerable maintenance after they are placed, and the maintenance often adversely affects 

the quality of life of patients. Tubes leak for various reasons. Standard biliary tubes consist of a catheter with  

side-holes and a distal locking loop. For the tube to work properly, the side-holes must be patent and properly 

positioned. The key to proper positioning is the proper location of the most peripheral side-hole. This hole should 

be located just inside the biliary duct where access was obtained. If the most peripheral side-hole of the catheter 

is malpositioned, leakage also occurs. Migration or malposition of the tube so that the hole is outside of the duct 

and in the parenchymal tract results in bile leaking back along the catheter onto the skin. If the hole is too far in, 

the bile duct peripheral to the catheter may become obstructed and leak along the course of the catheter. A careful 

cholangiogram and meticulous tube placement solve these problems. Another common cause of leakage is clogging 

of the side-holes of the catheter with viscous bile. This situation can be managed with catheter exchange with 

consideration given to upsizing the tube if the complication occurs frequently.

  9.  What are the potential complications associated with percutaneous transhepatic 

biliary drainage?

Even in the absence of clinical signs of cholangitis, bile in an obstructed system is often colonized with bacteria. Biliary 

sepsis, a potentially lethal complication, may occur during or after a cholangiogram or biliary drainage. Antibiotics should 

be given during a biliary drainage, and patients should be monitored closely for signs of sepsis. Injury to blood vessels 

adjacent to the bile ducts within the hepatic parenchyma may be associated with pseudoaneurysms, hemorrhage, and 

hemobilia. Bile leakage and bile peritonitis, and complications related to intraprocedural sedation (respiratory failure and 

aspiration) may occur. Pneumothorax and reactive or bilious pleural effusions are uncommon complications if care is 

taken during initial needle placement.

 10.  After an initial drainage procedure, what additional management measures may be 

performed to treat benign biliary obstruction?

Biliary drainage provides access to the bile ducts that may allow for retrieval of biliary calculi. Balloon dilation of benign 

ductal strictures with gradual upsizing of drainage catheter diameter may allow for remodeling of the bile duct with 

eventual relief of obstruction and removal of the drainage catheter. This therapy, when successful, usually takes several 

months. If unsuccessful, surgical intervention may still be possible, or catheters may be left in place for the long-term.

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Hepatobiliary and portal Venous interVentions

 11.  What can be done to manage the treatment of malignant biliary obstruction after 

initial drainage?

With some tumor types, access to the bile ducts allows for the placement of radioactive isotopes for ductal 

brachytherapy. If the patient is not a candidate for surgical resection, the drainage catheters may be left in long-term. 

Sometimes, internal metal stents may be placed across malignant strictures to allow for catheter removal for patient 

comfort. The decision to place a metallic stent depends on patient prognosis and life expectancy because internal metal 

stents have limited long-term patency.

 12.  What does the term isolated ducts mean? What is its significance?

In the case of a low obstruction of the common bile duct, the right and left systems still communicate. A right-sided 

biliary drain can be used to drain the right and the left sides. If the level of obstruction is higher, as might occur 

with cholangiocarcinoma, this might not be the case, and some ducts may not communicate with others—they are 

“isolated.” This is one reason why it is important to obtain cross-sectional imaging before biliary drainage. If only one 

ductal system is dilated, this information helps determine the access site (left-sided drainage vs. right-sided drainage). 

By definition, patients with isolated ducts have a portion of the biliary system that remains undrained if only a single 

catheter is placed. These patients may require more than one tube to treat infection, pruritus, or hyperbilirubinemia.

 13.  How does stricture morphology help differentiate between benign and malignant 

disease?

Benign strictures tend to taper smoothly, with gradual narrowing across their length. Malignant strictures, by contrast, 

are points of obstruction that end abruptly, sometimes with irregular borders or an appearance of “shouldering.”

 14.  If a histologic diagnosis is required, what methods may be used to obtain a biopsy 

specimen of the bile ducts?

When access to the bile ducts has been achieved, biopsy of a stricture site may be performed under fluoroscopic 

guidance. Various devices may be used to obtain tissue samples, including biopsy brushes, forceps, and needles. 

Often, several samples obtained on different days are required to obtain a diagnosis.

 15.  When is percutaneous cholecystostomy indicated?

Although cholecystectomy is the preferred therapy for acute cholecystitis, some patients may not be surgical candidates 

because of their overall clinical status, sepsis, or other comorbid conditions. Percutaneous cholecystostomy combined with 

broad-spectrum antibiotic coverage is a temporizing measure until the patient’s clinical status may be optimized for surgery.

 16.  Name the basic steps involved in performing percutaneous cholecystostomy.

With ultrasound (US) guidance, the gallbladder is accessed with a needle. A wire is placed, and after tract dilation, a 

drainage catheter is placed into the gallbladder and allowed to drain externally. A subcostal, transhepatic path to the 

gallbladder is generally preferred because it may guard against bile leakage into the peritoneal space if the catheter is 

inadvertently dislodged.

 17.  What are potential complications associated with percutaneous cholecystostomy?

Complications include hemorrhage, infection, bile peritonitis, and respiratory failure or aspiration related to 

intraprocedural sedation. Pneumothorax is possible, but relatively rare if a subcostal approach can be used.

 18.  How long must a percutaneous cholecystostomy catheter remain within the 

gallbladder before it can be removed?

Although some investigators have shown that catheters may sometimes be safely removed in less time, most believe 

that the cholecystostomy catheter should stay within the gallbladder for at least 4 to 6 weeks. This allows time for 

a mature tract to form between the gallbladder and skin surface in an effort to prevent bile leakage into the peritoneal 

space when the catheter is removed.

 19.  Should the cholecystostomy catheter be placed to external drainage indefinitely?

In the acute phase, although there is evidence of active inflammation, the catheter should be maintained on external 

drainage. In the setting of cholecystitis secondary to obstructing biliary calculi, the catheter should be maintained on 

external drainage. In the setting of acalculous cholecystitis, the catheter may be capped to allow for internal drainage 

after a cholangiogram is performed to document that there is no evidence of cystic duct obstruction.

 20.  When is transjugular liver biopsy indicated and preferred over percutaneous liver 

biopsy?

Because a transjugular liver biopsy specimen is obtained from within a hepatic vein, bleeding complications resulting 

from transgression of the liver capsule may be avoided. The transjugular procedure is indicated for patients with 

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interVentional radiology

coagulopathies or platelet deficiency. Platelet dysfunction because of renal failure may also be an indication. In addition, 

any other issue that may make percutaneous biopsy difficult or risky (e.g., ascites) would be a potential indication for 

transjugular liver biopsy. Because transjugular biopsy cannot generally be used to obtain tissue from a specific liver lesion, 

it is used only to obtain a tissue diagnosis for medical (diffuse) liver disease, such as viral hepatitis or transplant rejection.

 21.  How is transjugular liver biopsy performed?

A hepatic vein (most commonly, the right hepatic vein) is accessed using a transjugular approach (jugular vein to 

superior vena cava, through right atrium to inferior vena cava, and into right hepatic vein), and a stiff wire is placed. 

A stiff metal cannula is placed over the wire into the hepatic vein. An 18G or 19G core biopsy needle is placed through 

the cannula and used to obtain multiple samples of liver tissue. Because the right hepatic vein courses posteriorly 

through the right lobe, the needle is directed anteriorly to avoid transgression of the liver capsule. Because the middle 

hepatic vein courses more anteriorly, however, lateral or posterior sampling may be safer with this approach.

 22.  What are the clinical signs and symptoms associated with portal hypertension?

Esophageal, gastric, mesenteric, and rectal varices may bleed in response to elevated portal pressures; mortality from 

the initial bleeding episode may be 20% to 60%. Increased intrasinusoidal pressure may result in ascites and hepatic 

hydrothorax. Hepatic encephalopathy, hepatorenal syndrome with renal dysfunction, and hepatopulmonary syndrome 

with hypoxemia may also be encountered.

 23.  How can one indirectly estimate portal venous pressure to confirm the diagnosis 

of portal hypertension?

Catheterization of a hepatic vein is performed via jugular or femoral vein access. The catheter is advanced until it obstructs 

a small hepatic vein branch, or a balloon occlusion catheter is inflated within the hepatic vein to obstruct its outflow. The 

wedged hepatic vein pressure is actually a measure of sinusoidal pressure, but allows for a reasonable indirect estimate of 

portal pressure. A corrected sinusoidal pressure measurement is obtained by subtracting the measured free hepatic venous 

pressure from the wedged hepatic venous pressure. Corrected sinusoidal pressure measurements less than or equal to 

5 mm Hg are considered normal. Measurements of 6 to 10 mm Hg are compatible with mild portal hypertension, and 

measurements greater than 10 mm Hg are compatible with more severe portal hypertension.

 24.  What are the indications for creating a transjugular intrahepatic portosystemic shunt 

(TIPS)?

The most common indication for TIPS placement is variceal bleeding related to portal hypertension that is refractory to 

endoscopic therapy (

Fig. 34-5

). Other indications include refractory ascites or hepatic hydrothorax, Budd-Chiari syndrome, 

portal hypertensive gastropathy, and hepatorenal or hepatopulmonary syndrome. TIPS placement may be an effective 

bridge to liver transplantation for patients with end-stage liver disease and manifestations of portal hypertension.

25.  What are the contraindications to 

TIPS creation?

 

 A pre-TIPS total bilirubin level greater than 3 mg/

dL, refractory coagulopathy with an international 

normalized ratio greater than 1.8, a Child-Pugh 

score greater than 12, and a serum creatinine level 

greater than 1.9 mg/dL all have been found to be 

associated with poor outcomes. TIPS creation that is 

performed on an emergent basis is also associated 

with high mortality, and hemodynamic stabilization 

with transfusions, other medical interventions, and 

balloon tamponade of gastroesophageal varices are 

preferred before the TIPS procedure.

26.  Describe the steps of the TIPS 

procedure.

 

 

•

   A hepatic vein, most commonly the right hepatic vein, 

is accessed via a right internal jugular vein approach. 

A wedged hepatic venogram may be obtained to 

opacify the portal vein and map its location.

 

•

   A stiff metal cannula is placed, and a needle 

is passed from the right hepatic vein into the 

right portal vein under fluoroscopic guidance. 

Often, several needle passes are required to 

obtain portal access. The portosystemic pressure 

gradient measurement is obtained.

Figure 34-5. 

TIPS with a stent from the right hepatic vein to the right 

portal vein.

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Hepatobiliary and portal Venous interVentions

•

  A stiff wire is placed into the portal vein, and dilation of the intrahepatic parenchymal tract is performed with an 

angioplasty balloon.

•

  A flexible, self-expanding stent (usually 8 or 10 mm in diameter) is placed from the portal vein to the confluence of 

the hepatic vein with the inferior vena cava.

•

  A venogram and repeat portosystemic pressure gradient measurements are obtained.

 27.  What are the potential complications of TIPS creation?

Complications include hemorrhage, infection, allergic reaction to contrast agent, and respiratory failure or aspiration 

because of intraprocedural sedation. In addition, because the TIPS causes shunting of portal venous blood away from 

the liver, the procedure may be complicated by decline in liver function and hepatic encephalopathy.

 28.  What are the short-term and long-term goals of TIPS creation?

Successful TIPS creation is associated with a final portosystemic pressure gradient measurement of less than 

12 mm Hg to prevent variceal bleeding. If the TIPS has been placed to treat refractory ascites, lower pressures may 

be necessary for success (

≤8 mm Hg). If the patient has significant encephalopathy, and treatment with lactulose is 

insufficient to control symptoms, a reducing stent may be placed into the TIPS to create an intentional increase in the 

portosystemic pressure gradient. TIPS patency should be monitored at intervals using duplex Doppler US, which allows 

velocity measurements within the TIPS to be obtained noninvasively. Significant velocity increases from baseline may 

indicate the presence of TIPS stenosis, which may prompt TIPS venography and revision by balloon dilation or additional 

stent placement.

B

iBliography

[1]  J.M. LaBerge, A.C. Venbrux (Eds.), SCVIR Syllabus: Biliary Interventions, SCVIR, Fairfax, VA, 1995.

[2]  N.H. Patel, Z.J. Haskal, R.K. Kerlan (Eds.), SCVIR Syllabus: Portal Hypertension: Diagnosis and Interventions, second ed., SCVIR, Fairfax, VA, 

2001.