Major Haemorrhage Following a Transjugular Liver Biopsy: A Case Report and a Discussion of Complications and Learning Points

Abstract

Liver biopsy can be performed percutaneously, or via a transjugular approach. Transjugular liver biopsy (TJLB) is usually used in patients who are suffering from severe coagulation disorders (prolonged prothrombin time or low platelets), ascites, severe obesity, or failure of a previous non-targeted percutaneous liver biopsy. In TJLB, the biopsy needle is inserted into the liver parenchyma via the hepatic vein, avoiding transgression of the hepatic capsule and peritoneum. Unlike a percutaneous biopsy, a transjugular approach reduces the risk of bleeding as any bleeding from the biopsy site should be returned into the venous system. It is a safe, well-tolerated procedure, with a major complication rate of less than 0.6%. This case report describes the rare occurrence of a severe intraperitoneal haemorrhage post-TJLB, and describes and discusses the technique, complication profile, and learning points from this complication.

Keywords: haemorrhage; interventional radiology; major complications; patient consent; transjugular liver biopsy.

Figure 1. Fluoroscopic images of TJLB procedure

(A) 9Fr access catheter passed via right internal jugular vein to superior vena cava (blue arrows), with a stiff 0.035-inch guidewire passed to the right atrium (red arrow ). (B) Venogram of a 5Fr angled multipurpose catheter (red arrow indicating tip of catheter) accessing the right hepatic vein (blue arrow showing vein outlined by iodinated contrast. (C) The catheter (red arrow) can be passed distally into a wedge subsegment (blue circle) and used to estimate free, and wedge hepatic venous pressure. (D) When satisfactory position of the planned biopsy site has been confirmed, the needle (blue arrows) is deployed, and biopsies taken. TJLB: Transjugular Liver Biopsy; Fr: French

Figure 2. Triple phase CT of the liver following TJLB

(A) Unenhanced CT showing hyperdense fluid around the liver (red arrows), surrounded by less prominent hyperdense fluid (blue arrows), indicating intraperitoneal haemorrhage with sedimentation of blood into layers. (B) Arterial phase CT showing arterial phase contrast in the aorta (red circle) and hepatic arteries (red arrow) with no acute extravasation of contrast detectable around the liver. (C) Venous phase CT showing portal venous phase contrast in the aorta (red circle) and hepatic portal veins (blue arrow) with no acute extravasation of contrast detectable around the liver. TJLB: Transjugular Liver Biopsy

Figure 3. Digitally subtracted angiogram of the liver showing super-selection of a branch of a segment 4 artery (black arrow) with a 2.7Fr microcatheter (blue arrow), and a blush of contrast (red arrow) suggestive of the possible bleeding point

Fr: French