1. Retrospective Review of Transjugular Liver Biopsy in Patients with Left Lobe Only Liver Transplants
Brittany Bartolome, MSIII1; Andrew G. Taylor, M.D.2, Ph.D; Robert K. Kerlan, M.D.2
1University of Nevada School of Medicine; 2Department of Interventional Radiology, University of California, San Francisco
Introduction
Transjugular liver biopsy (TJLB) is an accepted technique for obtaining histologic samples from patients when percutaneous biopsy is considered difficult or high risk. The TJLB technique reduces the risk of bleeding since the sample can be obtained without puncturing the hepatic capsule. Therefore, TJLB is often used for patients who are at a higher risk for complications, particularly those who are obese, have underlying bleeding disorders, or ascites. The most common approach for whole livers transplants is to sample the tissue via the right hepatic vein (RHV) with an anteriorly directed needle pass to reduce bleeding. In left-lobe-only liver transplants, the technique must be modified to ensure a safe location and trajectory via the left hepatic vein (LHV). Thus far, evidence for successful TJLBs in left-lobe-only related transplants has been limited to pediatric cases of left split liver transplants. It remains unknown whether the safety and efficacy of the TJLB procedure follow similar success rates in adults receiving specifically a left-lobe transplant.
Methods
Patients
This retrospective study was approved by the UCSF IRB.
29 patients used in this study were selected for retrospective review based on the following:
Adult patients (>18 years old)
Received a living donor liver transplant of the left hepatic lobe with a left-lobe-only transjugular biopsy procedure.
Control group consisted of 30 adult transjugular biopsies performed via standard RHV approach receiving whole liver transplants.
Analysis
Patient charts were analyzed for procedural report, progress notes, and pathology report to identify post-operative complications, which included fever, neck hematoma, cardiac arrhythmias, pneumothorax, perforation of the liver capsule, fistula, and/or other forms of major bleeding.
Success rates of both transjugular approaches were compared via Excel sheet. Indicators of biopsy success included mean number of portal tracts, number of biopsy passes, mean diameter and length of specimens, and pathologic diagnosis.
We calculated the number of specimens considered adequate for histological diagnosis based on the pathologist report, those considered suboptimal or inadequate, and those with greater than 5 portal tracts.
Methods
TJLB Technique
Access to the venous system is obtained via a right internal jugular vein puncture. A 0.035" guide wire is placed into the IVC and a 9F sheath is placed over the wire after adequate dilatation. A guidewire and angled catheter are then used to gain entry into the left (or right) hepatic vein. A venogram is obtained to confirm the hepatic vein position. 
A long Trucut biopsy needle is then used to obtain 2-3 cores of liver parenchyma across the hepatic vein wall. The guiding sheath is turned to orient the needle into an area of liver parenchyma sufficient to yield 2 cm long core samples and avoid the liver capsule.
Results
Results
Discussion
Success Rates and Complications
In this study, no immediate complications or technical failures occurred during or following all procedures. Our findings indicate a complication rate of 14%, which falls within the reported ranged of 0-20% found in previous studies. This is consistent with the suspicion that the LHV approach can be implemented safely and successfully for liver transplant patients. The complications of fever and bleeding typically experienced with TJLB of the RHV occur at similar rates to those of LHV TJLBs. Only two minor bleeding issues were present among left-lobe-only cases and no incidences of severe post-operative complications or deaths were reported.
Discussion
Biopsy Adequacy
The rate of obtaining an adequate pathological specimen was lower for left-lobe biopsies (71%) than for whole-liver biopsies (85%), and the number of specimens containing greater than 5 portal tracts was substantially higher with the right hepatic vein approach in whole livers. This may be in part due to a tendency to take shorter samples when performing a left-lobe biopsy due to concerns about traversing the capsules in addition to overcoming the anatomical challenges between the transplanted left hepatic vein and native inferior vena cava. Yet, the technical challenges experienced with TJLB of the left hepatic vein were found to be similar to those found with the right and middle hepatic veins.
Conclusion
TJLBs approaching the LHV is a safe and effective approach for patients with a left-lobe-only liver transplant, with rates of technical success and complications falling within the reported range.
The LHV approach yields adequate samples and appears to have a comparable safety profile as the standard RHV technique.
Physicians should anticipate that 29% of biopsies may not be adequate, warranting either an alternative means of biopsy or immediate plan for treatment.
With the increase in left-lobe-only transplants, TJLB approach of the LHV may be the only safe and effective option for histological diagnosis.
The TJLB technique is preferred for patients with a history of bleeding disorders or for those presenting with complications such as ascites, coagulopathy, and thrombocytopenia that would contraindicate the percutaneous liver biopsy approach.
Clinicians should be aware of such liver biopsy options when presented with patients requiring hepatic assessment as a means of providing the least invasive and most optimal form of care.
References
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Figure 3 The average number of portal tracts identified by pathologists were 12 and 8.8 for whole liver and left-lobe-only, respectively. The average number of passes performed for whole and left-lobe-only transplants were 3.57 and 4.00 passes respectively (range, 2-6 in both transplant types).
Figure 4 Of the specimens obtained for diagnosis, 71% of all left-lobe-only procedures were considered adequate for histological diagnosis, whereas 85% of whole liver biopsy specimens were deemed adequate by the pathologist. When comparing those specimens containing >5 portal tracts, 12 cases (43%) of left-lobe-only biopsies and 23 cases (77%) of whole liver biopsies met this criterion.
Figure 1 In all TJLBs reviewed for this study, technical success was achieved without any immediate complications during biopsy procedures. Following TJLB, overall complication rates between whole liver and left-lobe-only TJLBs were similar, with bleeding being the most common, but very rare, complication. There were no biopsy-related deaths in either patient group.
Figure 2 Average specimen length was similar for both whole liver (1.298 cm) and left-lobe-only (1.288 cm) biopsies (range, and cm). Average diameter of specimens obtained was consistent between left-lobe-only and whole liver transplant groups.