Transjugular Liver Biopsy: What to do if there is an Unfavorable Cavo-Hepatic Angle?

Kaci M, Bassaid T, Baghdadi M, Bouakline Hand Zatir S4

Department of Gastroenterology, Oran Military Hospital, Algeria
Department of Medical Imaging, Oran Military Hospital, Algeria
Department of Pathology Anatomy, Oran Military Hospital, Algeria
Department of General Surgery, Military Hospital of Oran, Algeria

^*Correspondance to: Zatir S 

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Abstract:

Introduction: The lack of catheterization of the hepatic vein is the leading cause of failure of transjugular liver biopsy. Indeed, in some situations and following anatomical changes, the cavohepatic angle becomes too high, not favorable to the access of the needle, making the biopsy difficult or impossible. Several techniques have been described to overcome this difficulty; the purpose of this work is to show the interest of manual modification of the distal curvature of the metal cannula and its adaptation to the cavo-hepatic angle of the patient. Materials and Methods: In 28 patients with chronic liver disease who were candidates for transjugular liver biopsy, the cavo hepatic angle was measured systematically. A semi-automatic needle (18 gauges Quick-core set) with a rigid cannula with a 30° preformed distal end was used. The cavo-hepatic angle was estimated by tracing, on a digitized plate, a tangent to the dorsal spine, and that of the catheter in the hepatic position. When this angle was not favorable to the passage of the metal cannula, the distal end of the metal cannula was manually modified and adapted to the cavo-hepatic angle of the patient. We analyzed the values, the situations that can modify the cavo-hepatic angle and the methods used to facilitate the passage in the hepatic vein. Results: The cavo-hepatic angle averaged 48.2° (30° to 72°). In 32 patients (84.2%), he was less favorable at 60°. In 5 patients (18.5%), this angle was high, estimated on average at 68.1° (62° to 72°) unfavorable, it constituted an anatomical obstacle to the access of the metal cannula in the hepatic vein right. It was hypotrophic cirrhosis in 4 cases (66.6%) and ascites displacing the diaphragm upwards in 2 cases (33.3%). After failures of two attempts of its establishment at the hepatic level, the cannula was manually modified, accentuating its curvature to form a new angle measuring on average 50°. The biopsy was successfully performed in 4 cases.
A failure was due to the impossibility of accessing the right hepatic vein despite the technical modification, in a cirrhotic patient with significant hepatic atrophy having a cavo-hepatic angle at 72°. Liver tissue samples were obtained with 2 passages. The average length of the fragments was 13.5 mm (5 mm to 20 mm). A histological diagnosis was made in 20 cases (76.9%). Two minor complications were identified: spontaneously resolving supraventricular tachycardia related to the passage of the metallic guidewire in the right atrium, and bleeding at the cervical puncture site. No major complications have occurred.
Conclusion: The manual modification of the distal curvature of the semi-automatic needles and its adaptation to the cavo-hepatic angle of the patient makes it possible to access the liver with greater ease and safety and to reduce the failures of the hepatic biopsy by transjugular.

Keywords:

Transjugular liver biopsy; Liver cavitary angle; Tru-cut needle modification

Cite the Article:

Kaci M, Bassaid T, Baghdadi M, Bouakline H, Zatir S. Transjugular Liver Biopsy: What to do if there is an Unfavorable Cavo Hepatic Angle?. Clin Oncol. 2019;4:1668.