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Percutaneous transhepatic cholangiography

Percutaneous transhepatic cholangiography (PTC) is an image-guided, minimally invasive diagnostic and therapeutic procedure that involves inserting a needle through the skin and liver parenchyma to access the intrahepatic bile ducts, followed by the injection of iodinated contrast material to visualize the biliary tree under fluoroscopy or other imaging modalities.^[1] First reported in 1937 by Huard and Do-Xuan-Hop, PTC provides high-resolution imaging of biliary obstructions, strictures, stones, and leaks, serving as a critical tool when endoscopic approaches like ERCP are unsuccessful or contraindicated.^[1]^[2] The procedure is typically performed in a radiology suite under moderate sedation or local anesthesia, with ultrasound or fluoroscopic guidance to minimize risks; a fine needle, such as a 21- to 22-gauge Chiba needle, is advanced via an intercostal or subcostal approach into a peripheral bile duct, contrast is injected to opacify the ducts, and additional tools like guidewires or catheters may be deployed for interventions including biliary drainage, stent placement, or stone extraction.^[1]^[3] Indications for PTC include evaluating obstructive jaundice from malignant (e.g., cholangiocarcinoma, pancreatic cancer) or benign causes (e.g., choledocholithiasis, strictures), diagnosing postoperative bile leaks, obtaining biliary biopsies, and facilitating access in patients with altered gastrointestinal anatomy or failed ERCP attempts, with technical success rates of ≥90% in dilated ducts and ≥80% in nondilated ducts according to guidelines from the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).^[1]^[1] Although PTC is considered safe with a low overall complication rate of 2-10%, potential adverse events include hemorrhage (e.g., hemobilia or hematoma, especially with >5 needle passes), infection (e.g., cholangitis or sepsis, up to 43% in some series), bile peritonitis from leaks, pneumothorax (8-22% risk with intercostal access), and rare allergic reactions to contrast; contraindications encompass uncorrectable coagulopathy (e.g., INR >1.5 or platelets <50,000/μL), active infection, and pregnancy.^[1]^[1] Clinically, PTC plays a vital role in managing complex biliary diseases, often as a bridge to surgery or palliative care, and its use has evolved with advancements in imaging to reduce procedural attempts and improve outcomes.^[1]

Introduction

Definition

Percutaneous transhepatic cholangiography (PTC) is an image-guided, minimally invasive radiological procedure that involves the percutaneous insertion of a needle through the liver parenchyma to access the intrahepatic bile ducts, followed by the injection of iodinated contrast material to opacify and visualize the biliary tree under fluoroscopy.^[1] This technique enables direct radiographic imaging of the biliary system's anatomy and pathology, serving as a diagnostic tool for evaluating conditions such as obstructions, strictures, or leaks.^[4] The primary purpose of PTC is to provide detailed diagnostic imaging of the biliary tract in scenarios where non-invasive or endoscopic methods are inadequate, such as in patients with altered anatomy, failed endoscopic retrograde cholangiopancreatography (ERCP), or contraindications to endoscopy.^[1] It is particularly valuable for delineating the level and cause of biliary obstructions or anomalies, allowing for precise assessment that informs subsequent therapeutic interventions.^[4] While PTC can extend to therapeutic applications like biliary drainage or stone removal, its core role remains diagnostic visualization.^[1] Access during PTC targets the intrahepatic biliary system, which consists of segmental and sectoral ducts that branch from the left and right hepatic ducts at the porta hepatis, converging into the extrahepatic common hepatic duct.^[1] These peripheral intrahepatic ducts are opacified first, enabling retrograde filling and visualization of the downstream biliary tree, including the cystic duct and common bile duct.^[4] In comparison to non-invasive imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT) cholangiography, PTC offers superior spatial resolution for direct contrast-enhanced evaluation but is more invasive, carrying higher procedural risks and costs.^[1] It is typically reserved for cases where these less invasive alternatives provide insufficient detail.^[4]

Historical Background

Percutaneous transhepatic cholangiography (PTC) was first reported in 1937 by Huard and Do-Xuan-Hop, who utilized rudimentary needle techniques to achieve biliary opacification through direct puncture of the liver parenchyma.^[1] This initial approach involved injecting contrast media, such as Lipiodol, into the biliary ducts under blind guidance, marking an early invasive method for visualizing biliary obstructions despite high risks of bile leakage and limited success rates.^[5] The procedure gained wider acceptance following its popularization in 1952 by Carter and Saypol, who described transabdominal cholangiography performed under general anesthesia to improve visualization of the biliary tree in jaundiced patients. Further advancements came in 1960 with Atkinson, Happey, and Smiddy, who introduced safer access methods using a finer "skinny needle" technique and real-time roentgen television control, which enhanced precision and reduced complications during duct puncture.^[6] Initially confined to diagnostic purposes in the mid-20th century, PTC evolved into a procedure incorporating therapeutic elements by the 1970s, including percutaneous biliary drainage to manage obstructive jaundice and stone extraction.^[7] Key milestones in this period included the development of catheter-based drainage systems, transforming PTC from a purely imaging tool to one enabling interventional relief of biliary obstructions.^[8] In the 1980s, the introduction of ultrasound guidance significantly reduced procedural complications by allowing real-time visualization of needle trajectory without prior cholangiography, as demonstrated in early applications by Makuuchi et al.^[9] This established PTC as a reliable alternative when endoscopic approaches like ERCP were contraindicated.^[10]

Clinical Considerations

Indications

Percutaneous transhepatic cholangiography (PTC) is primarily indicated in scenarios where endoscopic retrograde cholangiopancreatography (ERCP) has failed or is inaccessible due to altered anatomy, such as post-gastrectomy states, hilar obstructions, or proximal biliary strictures.^[11]^[1] This approach is particularly valuable for delineating the biliary tree in patients with intrahepatic dilatation or when retrograde access is precluded by anatomical variations.^[12] Diagnostically, PTC facilitates evaluation of obstructive jaundice by defining the level and etiology of biliary obstruction, including assessment for cholangiocarcinoma, benign strictures, or inflammatory disorders.^[13] It also enables visualization of bile leaks following surgery when ERCP is unsuccessful or contraindicated, and aids in detecting suspected bile duct stones or choledochal cysts.^[1]^[13] Therapeutically, PTC often precedes interventions such as stent placement for palliation in malignant biliary obstructions or biliary drainage to manage cholangitis and decompress the obstructed biliary tree.^[1]^[12] It supports dilation of strictures and diversion of bile in cases of leaks, particularly when endoscopic methods are not feasible.^[13] In special cases, PTC is employed for drainage of hydatid cysts with rupture into the biliary system, providing an effective minimally invasive route to alleviate obstructive complications.^[14] Recent studies from 2023 to 2025 highlight its efficacy in non-surgical candidates with intrahepatic cholangiocarcinoma (ICC) presenting with jaundice, where it improves outcomes when combined with therapies like drug-eluting bead transarterial chemoembolization.^[15]^[16]

Contraindications

Percutaneous transhepatic cholangiography (PTC) has specific absolute contraindications that preclude its performance due to unacceptable risks of severe complications. Severe coagulopathy, defined as a platelet count below 50 × 10⁹/L or an international normalized ratio (INR) greater than 1.5, is an absolute contraindication because it significantly increases the risk of hemorrhage during needle puncture through the liver parenchyma.^[1] Uncontrolled ascites represents another absolute contraindication, as the lack of tamponade from surrounding solid tissue heightens the potential for fatal intraperitoneal bleeding or peritonitis following puncture.^[4] Additionally, active biliary sepsis without a concurrent plan for immediate biliary drainage is contraindicated, owing to the elevated risk of disseminating infection systemically or forming hepatic abscesses during the procedure.^[4] Early pregnancy is an absolute contraindication due to the risk of ionizing radiation exposure to the fetus. Nondilated intrahepatic bile ducts are also absolute, as they reduce technical success rates and increase complication risks. Life expectancy less than 30 days and unstable hemodynamics or extensive hepatic disease further contraindicate the procedure, as risks outweigh potential benefits per guidelines.^[1] Relative contraindications involve conditions where the procedure may be considered if the clinical benefits outweigh the risks, often after mitigation strategies. Mild bleeding risks, such as platelet counts between 50 and 100 × 10⁹/L or prothrombin time prolonged by 1-2 seconds, are relative contraindications that require careful evaluation and potential correction prior to intervention.^[1] Prior liver surgery can complicate access by altering anatomical landmarks and increasing the difficulty of safe needle trajectory, making it a relative contraindication in such cases.^[12] Allergy to iodinated contrast media is also relative, as premedication with corticosteroids and antihistamines can often allow the procedure to proceed safely.^[1] Special considerations further guide patient selection to minimize rare but serious risks. In patients with hepatocellular carcinoma, there is a rare risk of tumor seeding along the needle tract, which may lead to peritoneal metastasis; preventive measures such as selecting an appropriate access route are recommended.^[17] For distal biliary obstructions, endoscopic retrograde cholangiopancreatography (ERCP) is preferred as the initial approach, reserving PTC for cases where ERCP is unsuccessful or infeasible.^[18] Pre-procedure assessment is essential to address modifiable contraindications, particularly coagulation abnormalities. Correction of coagulopathy may involve administration of vitamin K for several days to normalize INR in non-emergent cases, or fresh frozen plasma (FFP) immediately before or during the procedure in urgent situations.^[4] This targeted optimization helps ensure safer execution when relative contraindications are present.

Procedure

Preparation

Patients undergoing percutaneous transhepatic cholangiography (PTC) are typically required to fast for 4 to 6 hours prior to the procedure to minimize the risk of aspiration, particularly if sedation is anticipated, with confirmation of nil per os (NPO) status by the medical team.^[3]^[19] Pre-procedure laboratory evaluation is essential to assess patient suitability and mitigate risks. Coagulation studies, including prothrombin time (PT), international normalized ratio (INR), and platelet count, are obtained to identify and correct coagulopathy; guidelines recommend maintaining an INR of ≤1.5 and platelet count ≥50,000/μL, with reversal using vitamin K (administered for 3 days) or fresh frozen plasma if necessary.^[1]^[11] Liver function tests, such as serum bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST), provide baseline assessment of hepatic status and biliary obstruction severity.^[20] Renal function is evaluated via serum creatinine to ensure adequate contrast clearance, with intravenous hydration recommended for at-risk patients to prevent contrast-induced nephropathy or hepatorenal syndrome.^[1] Prophylactic medications are administered to reduce infectious and hemorrhagic complications. Broad-spectrum antibiotics targeting gram-negative organisms, such as ceftriaxone 1 g intravenously or ciprofloxacin 400 mg intravenously (particularly in penicillin-allergic patients), are given prior to needle puncture to prevent cholangitis, with a single dose often sufficient for diagnostic PTC.^[1]^[21] Coagulopathy reversal, if indicated by laboratory results, may involve fresh frozen plasma or other agents to normalize hemostasis before proceeding.^[11] Informed consent is obtained after a thorough discussion of procedure benefits, alternatives, and risks, including potential bleeding, infection, and contrast reactions, ensuring patient understanding and autonomy.^[1] Pre-procedure imaging review, such as ultrasound or magnetic resonance imaging (MRI), is conducted to delineate bile duct anatomy, confirm dilation, and plan the optimal access route, which may also identify absolute contraindications like uncorrectable coagulopathy during this evaluation.^[1]

Technique

The patient is typically positioned supine on the fluoroscopy table to facilitate access to the right hepatic lobe, although the right lateral decubitus position may be used in select cases to optimize visualization and reduce respiratory interference.^[1] Local anesthesia with lidocaine is administered to the skin and subcutaneous tissues at the puncture site, often combined with intravenous sedation using agents such as midazolam and fentanyl to ensure patient comfort and cooperation during the procedure.^[1]^[22] Under real-time ultrasound guidance, a 22-gauge Chiba needle is advanced intercostally through the right mid-axillary line, caudal to the 10th rib, targeting a peripheral dilated intrahepatic bile duct in the right hepatic lobe.^[11]^[1] The needle trajectory is angled cephalad toward the porta hepatis to minimize traversal of liver parenchyma, and successful entry into the biliary system is confirmed by gentle aspiration of bile, which provides immediate verification of position without the need for initial contrast.^[11] In patients with non-dilated ducts or challenging anatomy, such as obesity, ultrasound is preferred for its ability to delineate vascular structures and guide precise puncture.^[1] Once positioned, low-osmolar non-ionic iodinated contrast medium (concentration 150-300 mgI/ml) is slowly injected through the needle in a volume of 20-60 ml under continuous fluoroscopic monitoring to opacify the intrahepatic and extrahepatic biliary tree in real time.^[1] Fluoroscopy in multiple projections, including anteroposterior, right anterior oblique, and left anterior oblique views, allows dynamic assessment of biliary anatomy, filling defects, and any obstructions as the contrast flows toward the duodenum.^[11] Care is taken to inject incrementally to avoid overdistension and potential complications like bile leakage. Recent advancements include contrast-enhanced ultrasound (CEUS) guidance, which enhances visualization of non-dilated ducts by providing superior acoustic enhancement and real-time confirmation of needle placement, as validated in 2024 studies demonstrating 100% technical success in malignant biliary obstruction cases with ducts ≤4 mm in diameter.^[23] Hybrid techniques incorporating endoscopic rendezvous have also emerged for complex cases, combining percutaneous access with endoscopic visualization to improve overall procedural efficacy.^[1] Upon completion of imaging, the needle is carefully withdrawn, and direct pressure is applied to the puncture site for hemostasis, followed by application of a sterile dressing.^[1] If therapeutic intervention is planned, a temporary catheter may be left in place, but for diagnostic purposes, the procedure concludes with needle removal and post-procedural monitoring.^[11]

Complications

Types

The complications of percutaneous transhepatic cholangiography (PTC) can be categorized into immediate, infectious, procedural, and long-term types, with an overall incidence rate of 5-10% and mortality less than 1%.^[1] Immediate complications primarily include hemorrhage, bile leak leading to peritonitis, and contrast extravasation. Major bleeding occurs in 1-3% of cases, with higher rates in patients with coagulopathy, manifesting as hemobilia, hematoma, or hemoperitoneum.^[24] Bile leaks, which may result in peritonitis or biloma formation, arise from ductal perforation during needle insertion.^[1] Infectious complications are common, with cholangitis affecting 5-10% of patients and sepsis developing from bacteremia in a subset of cases; notably, the risk of pancreatitis is lower compared to endoscopic retrograde cholangiopancreatography (ERCP).^[25] These infections often stem from bacterial introduction into the biliary system, particularly in obstructed ducts.^[1] Procedural complications involve needle tract issues, such as pneumothorax (incidence 8-22% with intercostal or transpleural approaches) and tumor seeding in patients with hepatocellular carcinoma (HCC), reported in up to 5% of malignancy cases.^[1]^[26] Tumor seeding occurs via implantation of malignant cells along the puncture tract.^[27] Long-term complications encompass metastasis along the needle tract and biliary stricture formation, potentially contributing to recurrent obstruction. Recent meta-analyses from 2023 indicate overall similar complication rates between PTC and ERCP, with PTC associated with higher bleeding risk in some studies but lower rates of infection and pancreatitis.^[28]^[25] Prophylactic antibiotics may mitigate infectious risks in select cases.^[1]

Management and Prevention

Prevention of complications in percutaneous transhepatic cholangiography begins with pre-procedure coagulation optimization, targeting an international normalized ratio (INR) of ≤1.5 and platelet count of ≥50,000/μL as recommended by the Society of Interventional Radiology to minimize bleeding risks.^[1] Ultrasound guidance is employed to accurately access bile ducts, reducing the number of puncture attempts and associated vascular injuries.^[1] Prophylactic antibiotics, such as a single intravenous dose of a third-generation cephalosporin or 1 g ceftriaxone combined with 1.5 g ampicillin-sulbactam, are administered to prevent infections like cholangitis.^[1] Following the procedure, patients undergo observation for 4-6 hours, including bed rest and monitoring for immediate signs of hemorrhage or infection.^[29] Management of bleeding complications involves initial application of direct compression at the puncture site to achieve hemostasis, followed by close monitoring of hemoglobin levels and vital signs for hemodynamic instability.^[1] If bleeding persists, arterial embolization using coils or other agents is performed via femoral or radial access to occlude the affected vessel, while significant blood loss may necessitate transfusion to maintain adequate hematocrit.^[1] For infection control, particularly in cases of suspected sepsis or cholangitis, broad-spectrum intravenous antibiotics such as piperacillin-tazobactam are initiated promptly, with bile sampling for microbial culture to guide targeted therapy.^[1] Placement of a drainage catheter is indicated to decompress the biliary system and evacuate infected material if an abscess or persistent biloma is identified.^[1] Post-procedure follow-up includes imaging such as ultrasound or computed tomography at 24-48 hours to detect bile leaks or collections, alongside patient education on recognizing warning signs like fever, chills, or abdominal pain, prompting immediate medical attention.^[1] Recent studies from 2024-2025 highlight the value of early percutaneous transhepatic cholangiography drainage in high-risk intrahepatic cholangiocarcinoma patients with obstructive jaundice, demonstrating improved overall survival (14 months vs. 11 months) and reduced jaundice-related morbidity when combined with other therapies like drug-eluting bead transarterial chemoembolization, without increasing severe adverse events.^[15]

Percutaneous Transhepatic Biliary Drainage

Percutaneous transhepatic biliary drainage (PTBD) is indicated primarily for the management of obstructive jaundice that is unresponsive to endoscopic retrograde cholangiopancreatography (ERCP), particularly in cases involving hilar cholangiocarcinoma or post-surgical biliary strictures.^[30]^[31] This procedure serves as a palliative or bridge therapy to relieve biliary obstruction and improve liver function when endoscopic access is challenging due to anatomical alterations or tumor location.^[32] The procedure builds on percutaneous transhepatic cholangiography (PTC) as the initial access step, where a needle is used to opacify the biliary system.^[1] Following successful biliary access, a guidewire is advanced through the obstruction into the duodenum or proximal bowel, the tract is dilated progressively, and an internal-external drainage catheter—typically an 8- to 10-Fr pigtail—is placed to allow bile drainage both internally past the obstruction and externally via a collection bag.^[20]^[33] Fluoroscopic guidance ensures precise catheter positioning, with internal drainage preferred when possible to maintain antegrade flow.^[34] Clinical outcomes demonstrate effective relief of jaundice, with bilirubin levels reducing in 70-90% of cases, achieving clinical success rates around 81.6% and significant decreases in median serum bilirubin (e.g., from 15.67 mg/dL pre-procedure).^[35]^[32] Recent 2025 studies affirm the safety of PTBD in malignant hepatic biliary obstruction (MHBO), reporting low overall complication rates, including catheter dislodgement in approximately 5-10% of cases, which can often be managed with repositioning.^[32]^[17] Compared to ERCP, PTBD offers advantages in accessing proximal or hilar lesions, allowing targeted drainage of specific ducts to maximize functional liver drainage.^[36] However, it carries a higher risk of bleeding, occurring in 2-5% of procedures, due to potential vascular injury during tract creation.^[37]^[38] Post-procedure catheter care involves daily flushing with 5-10 mL of sterile water or saline to prevent occlusion, along with monitoring for signs of infection or blockage.^[33] Catheters are typically exchanged every 4-6 weeks to maintain patency and reduce infection risk, with adjustments based on patient symptoms or imaging follow-up.^[33]^[39]

Percutaneous Extraction of Retained Biliary Calculi

Percutaneous extraction of retained biliary calculi is indicated in cases where endoscopic retrograde cholangiopancreatography (ERCP) has failed, particularly for stones larger than 15 mm, which are associated with increased difficulty in endoscopic removal.^[40] It is also suitable for patients with altered anatomy, such as Billroth II gastrectomy, that complicates endoscopic access.^[41] Additionally, this approach addresses residual stones following cholecystectomy, occurring in approximately 5% of such cases.^[42] The percutaneous transhepatic approach utilizes a mature tract established via prior percutaneous transhepatic biliary drainage (PTBD), typically allowing intervention 1-2 weeks after initial catheter placement to ensure tract development and biliary decompression.^[43] Under fluoroscopic guidance, access is gained through the matured tract using 5-7 Fr catheters, followed by advancement of a Dormia basket or balloon catheter to grasp or push the calculi toward the duodenum.^[43]^[44] For larger stones, adjunctive lithotripsy techniques, such as electrohydraulic or laser methods, may be employed to fragment the calculi prior to extraction.^[45] In the trans T-tube approach, extraction occurs 5-8 weeks post-surgery after the T-tube sinus tract has matured, minimizing risks of bile leakage.^[46] The procedure begins with T-tube removal, followed by guidewire insertion into the biliary system, contrast cholangiography to localize stones, and mechanical extraction using a Dormia basket or balloon via the sinus tract.^[47]^[42] Overall success rates for percutaneous extraction range from 85% to 95%, with techniques demonstrating high efficacy in difficult cases refractory to endoscopy.^[48] Recent 2024 studies confirm these outcomes, reporting technical success up to 100% and low stone recurrence rates of around 10% at one year in challenging scenarios.^[49]

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