AJR 2003; 181:1017-1020
© American Roentgen Ray Society
Usefulness of a Percutaneous Transhepatic Coaxial Micropuncture Needle Technique in Patients with Nondilated Peripheral Intrahepatic Ducts
Constantin Cope1
1 Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
Received December 30, 2002;
accepted after revision April 29, 2003.
Address correspondence to C. Cope
(cope{at}oasis.rad.upenn.edu).
Abstract
OBJECTIVE. I sought to develop an efficacious transhepatic technique
for localizing normal or minimally dilated biliary radicles using 25- to
27-gauge needles threaded through 21- to 22-gauge needles.
CONCLUSION. The micropuncture needle is a useful adjunct for
performing transhepatic cholangiography in patients whose bile ducts are
nondilated or in whom the standard transhepatic needle technique has
failed.
Introduction
Percutaneous transhepatic cholangiography (PTC) of dilated bile ducts is
almost universally successful but may require as many as 15–20
transhepatic needle passes [1].
When applied to patients with nondilated ducts, the technical success rate of
this procedure is reduced to approximately 60%, with a range of 25% to 85%
[2]; the use of sonographic
guidance is of no additional value in these patients. Although it is claimed
that PTC is not associated with any major complications even after 50
transhepatic needle passes [3],
this procedure can lead, in our experience, to severe abdominal pain after as
few as six needle passes, which in some patients is severe enough to
discontinue the procedure. Further discomfort and the potential for hemorrhage
can also be expected if a second transhepatic needle needs to be inserted to
access a more suitable duct for insertion of biliary drains
[4,
5].
In an effort to render PTC before catheter drainage more successful,
especially in patients with nondilated ducts, my colleagues and I experimented
with a coaxial technique using microneedles threaded through Chiba needles.
With the use of this simple modification, PTC was successfully performed in
most cases with only two to three microneedle passes, even after the standard
Chiba needle technique had failed.
Materials and Methods
This was a 4-year study to evaluate the potential advantages of using a
coaxial micropuncture technique for performing PTC primarily in patients with
nondilated peripheral intrahepatic bile ducts. The purpose of the study was to
assess whether this technique could lead to a significantly reduced number of
failed transhepatic needle passes.
The cohort included 19 patients: 12 men and seven women who were
29–77 years old (mean age, 57 years). All patients had minor to moderate
evidence of cholestasis or abdominal pain associated with abnormal results on
liver function tests. Endoscopic retrograde cholangiopancreatography (ERCP)
had either been unsuccessful or deemed unsuitable for all the patients. Only
four of the 19 showed dilated ducts on contrast-infused CT. Patients had PTC
for diagnosis and drainage of benign strictures (n = 4), malignant
strictures (n = 7), liver transplant malfunctions (n = 3),
possible calculi (n = 3), and postlaparoscopic cholecystectomy
complications (n = 2). The coaxial needle technique was used either
de novo or after failure of the standard Chiba needle technique, primarily in
patients who had nondilated ducts (n = 15); it was also successfully
used in four patients with central duct dilatation in whom the Chiba technique
had failed after six to 10 transhepatic needle passes.
Before transhepatic insertion of the Chiba needle, the distal 2–3 cm
of the needle was gently bent by finger pressure
(Fig. 1) to allow the
microneedle to be redirected without withdrawing the outer guiding needle
[6].
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Fig. 1. —Photograph shows 23-cm-long, 27-gauge (ga) micropuncture
needle and 15-cm-long 22-gauge Chiba needle. Micropuncture needle fits through
larger-gauge needle. Note bent tip of Chiba needle.
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The first four patients underwent PTC with a coaxial 25-gauge needle passed
through a 21-gauge needle, but subsequently we used 23-cm-long 26- or 27-gauge
needles with a Huber point (Popper and Sons, New Hyde Park, NY) inserted
through 15-cm-long 21- or 22-gauge Chiba needles.
After a local anesthetic was applied to the right ninth or 10th intercostal
space slightly anterior to the midaxillary line, the styletted bent Chiba
needle was advanced under fluoroscopic guidance to a 2- to 3-cm depth within
the liver parenchyma during breath-holding. The micropuncture needle was
threaded through the introducing needle to the region of the portahepatis, and
undiluted contrast medium was inserted slowly and continuously through the
microneedle via a flexible connecting tube while slowly withdrawing the needle
under close fluoroscopic monitoring. As soon as a small ductlike structure was
identified, further contrast medium was injected with the needle held
stationary until it was clear whether this structure was a lymph vessel
(Fig. 2) or a bile radicle. If
there was no opacification of the duct, the bent-tipped Chiba needle was
slightly rotated to face a different segment of the liver, and the microneedle
was readvanced. Infusion of contrast medium needed to be slow to ensure
optimal opacification of tiny ducts and to prevent gross extravasation.
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Fig. 2. —64-year-old man with history of common bile duct calculi and
nondilated ducts. Needle hepatogram shows injection through micropuncture
needle that was advanced through Chiba needle, revealing opacification of
lymphatics during initial needle pullback.
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If a third- to fourth-order opacified duct was judged to be suitable for
catheterization, the Chiba needle was telescoped over the microneedle to the
bile duct lumen; the microneedle was removed to allow a 0.018-in
microguidewire to be threaded to the common bile duct for subsequent drain
insertion (Fig. 3A,
3B). If the needle had entered
a bile duct that was too central or at a bad angle for direct catheterization,
it was kept in place for further opacification of the intrahepatic biliary
system while a second puncture was made to access a more suitable peripheral
bile duct. A similar technique was used for the left transhepatic approach.
All studies were performed by a supervised house officer or the author.
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Fig. 3A. —64-year-old man with suspected anastomotic duct stenosis
after liver transplantation. Percutaneous transhepatic cholangiogram shows
Chiba needle threaded over microneedle that has punctured tiny bile duct
branch. Microneedle was subsequently removed to allow 0.018-inch guidewire to
be advanced to bowel.
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Fig. 3B. —64-year-old man with suspected anastomotic duct stenosis
after liver transplantation. Cholangiogram shows final insertion of 8.3-French
biliary internal–external drain after transhepatic tract dilatation.
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Results
Despite their small gauge and flexibility, 26- to 27-gauge needles
supported by Chiba needles were painlessly and easily passed through the liver
parenchyma with little deflection. Lymphatic vessels were shown in 47%
(n = 9) of patients. PTC with the microneedle was successfully
performed in all 19 patients.
The slow injection of contrast medium through the microneedle had the
advantage of providing early opacification of small ducts unobscured by major
staining of the liver parenchyma.
Bile duct branches were successfully opacified within three transhepatic
microneedle passes in 17 patients and after 10 and 15 passes in two other
subjects with normally sized ducts. Bile duct branches were opacified with the
microneedle either directly in 13 patients or indirectly from a parenchymal
blush of contrast medium in six patients
(Fig. 4). Although all patients
had nondilated peripheral intrahepatic bile duct branches on cholangiography,
central ducts were found to be normal in seven, slightly dilated in eight, and
dilated in four.
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Fig. 4. —Indirect percutaneous transhepatic cholangiogram in
47-year-old man with liver transplant malfunction. Duct opacification has
occurred from parenchymal sinusoidal blush of contrast medium without overt
coaxial microneedle puncture of duct. Second puncture was required to insert
transhepatic drain catheter.
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It was possible to advance the Chiba needle over the microneedle in 52% of
the patients to allow immediate insertion of a guidewire for common bile duct
catheterization (Fig. 3A,
3B); the duct caliber of those
patients was found to be normal in two, slightly dilated in five, and
significantly dilated in three. In the remaining nine subjects, the standard
Chiba needle technique was used for locating a more suitable catheterization
site, using the initial duct opacification for guidance. In six of these
patients, bile ducts were opacified indirectly by microneedle injection from a
parenchymal stain of contrast medium without traversing a recognizable bile
duct (Fig. 4).
Sixteen internal–external biliary drains and one stent were inserted
after PTC with the coaxial needle technique; in two patients, repeated
attempts to puncture small preopacified ducts with a 21-gauge needle had to be
cut short when the patients experienced severe abdominal pain. No other
morbidity was observed.
Discussion
In this preliminary study, we found that the use of the coaxial technique
in patients with nondilated bile ducts resulted in successful cholangiography
usually after only two or three transhepatic microneedle passes, thus allowing
PTC to be performed more quickly, with less need for contrast medium and with
less patient discomfort. The results compare favorably with those of Funaki et
al. [3], who used as many as 50
transhepatic needle passes to achieve a 90% success rate.
The Chiba needle technique has about a 30–40% failure rate for
accessing small ducts. PTC failures also have occurred in some patients who
have dilated central hepatic ducts drained from peripheral ducts that are
normal, slightly dilated, or have skip dilatations
[7].
It is possible that Chiba needles may compress, fail to penetrate, or slip
off the thick fibrous walls of small bile ducts because they are
proportionately too large or too blunt. In contrast, micropuncture needles
that have a three to four times smaller cross-section than Chiba needles,
provide less transtissue resistance and are sharper implements that can
enhance clean intraluminal access to small 1- to 2-mm ducts. This technique
led to direct duct punctures in 13 patients; in 10 of these, favorable
alignment of the microneedle allowed the Chiba needle to be directly
telescoped to the duct lumen to permit uncomplicated guidewire and drain
insertion. In six of the 19 patients, bile duct opacification occurred
indirectly from a neighboring sinusoidal parenchymal blush thus raising the
possibility that tiny biliary ductules had been injected
(Fig. 4). In the nine patients
in whom it was not possible to use the coaxial needle technique for immediate
catheterization, the preopacified ducts were punctured with a separate
21-gauge needle. This often required multiple passes; the procedure failed in
two patients. Similar difficulties have been encountered by others
[2]. The puncture of central
ducts is easier but may be associated with a higher incidence of hemorrhagic
complications [2].
The success of the microneedle technique for accessing small peripheral
bile ducts, usually within three transhepatic passes and either de novo or
after an unsuccessful standard PTC technique, appears to be promising on the
basis of the results of this small study. PTC proved to be especially useful
and nontraumatic in 10 patients in whom it was possible to directly telescope
the Chiba needle over the micropuncture needle for immediate guidewire
insertion. Prospective comparison of the coaxial micropuncture needle
technique with standard PTC will be difficult to obtain because most patients
with normal ducts are evaluated by ERCP.
We found it noteworthy that transhepatic injection of contrast medium with
the microneedle led to lymphatic opacification in 47% of patients
(Fig. 2), compared with 15%
obtained with the Chiba needle in the larger series of 800 patients by Okuda
et al. [8]. This finding may be
due to the fact that nondilated lymphatic channels can be more cleanly
punctured with the microneedle than with the proportionately much larger Chiba
needle. Although dilated intrahepatic lymphatics are readily seen after
intraparenchymal injection of contrast medium in patients with diseases
causing hepatic lymph obstruction
[9], none of our patients had
overt evidence of chronic diffuse sinusoidal fibrosis.
In conclusion, the coaxial micropuncture technique provided the following
advantages: a high success rate with fewer needle passes in nondilated bile
ducts, ability to telescope the Chiba needle over the microneedle for
immediate duct drainage in more than 50% of cases, indirect opacification of
bile ducts from a parenchymal sinusoidal blush of contrast medium, successful
duct opacification when the standard Chiba needle technique failed, and a 90%
success rate in post-PTC bile duct catheterization.
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Abstract
Introduction
