Transvenous Liver Biopsy Research Articles

A multiple variable index and extracardiac-Fontan associated hepatic fibrosis

BackgroundThe serial follow-up of Fontan-associated liver disease is challenging, as laboratory values are frequently normal, especially with mild to moderate liver disease. ObjectiveWe investigated a composite index's correlation with hepatic biopsy total fibrosis scores in extracardiac Fontan patients. MethodsWe identified extracardiac Fontan patients undergoing cardiac catheterization and transvenous hepatic biopsies between June 2013 and September 2023 and liver shear wave elastography between January 2017 and July 2023. We developed a composite index from the following: 1) elastography values, 2) sex, 3) history of a neonatal aortopulmonary shunt for pulmonary flow obstruction, 4) pacemaker, 5) Fontan duration, 6) bilirubin values, 7) univentricular dysfunction, 8) atrioventricular valvar regurgitation, 9) mean Fontan pressures, and 10) venovenous collaterals presence. We correlated the index with hepatic total fibrosis scores (0–8), the sum of pathology grading (0 to 4) performed for sinusoidal and portal fibrosis. We defined a hepatic total fibrosis score of 0–3 as none to mild and 4–8 as moderate to severe fibrosis. ResultsWe identified 62 patients who underwent 92 transvenous liver biopsies, with 30 patients undergoing 2 biopsies. The average age at biopsy was 15 ± 2 years. We found a strong correlation (rho = 0.8, p = .00001) between liver total fibrosis scores and composite index values. A receiver operating characteristic analysis demonstrated that an index cut-off value of ≥26 predicted a total fibrosis score of ≥4 with a sensitivity of 71 % and a specificity of 75 % (AUC = 0.73, 95 % CI 0.63, 0.83, p = .0001). ConclusionsWe developed a composite index with a moderate predictive ability to discriminate none to mild from moderate to severe hepatic fibrosis. Nevertheless, additional data is needed to assist further validation and determine its clinical utility in the serial follow-up of Fontan associated liver disease.

Liver Decompensation after Bariatric Surgery in the Absence of Cirrhosis.

Metabolic dysfunction-associated fatty liver disease-related cirrhosis is possible at the time of bariatric surgery, complicated by further liver decompensation. Hepatic decompensation can also occur in the absence of cirrhosis but the presentation is less clear. We analyze the clinical characteristics, histological findings, and management of patients without cirrhosis who developed hepatic decompensation after bariatric surgery in our single tertiary-care hospital. From 2014 to 2019, 6 patients underwent a transvenous liver biopsy for liver decompensation after bariatric surgery. Mean age at diagnosis was 44 years. The time between bariatric surgery and the onset of symptoms varied widely (min. 8 months, max. 17 years). Mean % of weight loss was high at 43%. The clinical presentation was as follows: fatigue and jaundice (5/6), leg edema (3/6), and ascites (1/6). Blood test showed increased transaminases (mean ALT 53 UI/L, mean AST 130 UI/L), bilirubin (mean 6 mg/dL), and INR (mean 1.5) with a low albumin level (mean 27 mg/dL). The hepatic venous pressure gradient was high (mean 10 mmHg). Histology revealed steatosis, hepatocyte ballooning but also portal inflammation with polymorphonuclear cells, and bile duct alterations. Mean fibrosis score was 2. The clinical course was favorable with nutritional support with a mean follow-up of 36 months. Liver decompensation in the absence of cirrhosis can occur after bariatric surgery with a highly variable delay. A special histological signature is present with the coexistence of steatosis, bile duct alterations, and portal inflammation. Substantial clinical improvement with appropriate nutritional support seems to be effective.

Utility of transient elastography in evaluation and follow-up of Budd-Chiari syndrome patients after endovascular intervention

BackgroundLiver stiffness measurement (LSM) using transient elastography (TE) is a common noninvasive method for assessing hepatic fibrosis. The purpose of this study was to show the utility of LSM in the evaluation and short-term follow-up of Budd-Chiarri syndrome (BCS) patients as well as to investigate the relationships between LSM, hepatic venous pressure, and liver fibrosis. We conducted a prospective cohort study in which 25 patients with a confirmed diagnosis of primary BCS underwent endovascular intervention for BCS treatment. All patients had pressure gradient changes across the stenosed hepatic veins/inferior vena cava (HV/IVC) measured before and after the procedure, a transvenous liver biopsy during the procedure, and LSM (using Transient Elastography 3 days before and 3 months after the intervention as a short-term follow-up). Comparisons and correlations were made between liver stiffness, hepatic venous pressure, and fibrosis.ResultsThe HV/IVC pressure gradient measured immediately before and after the intervention had a direct proportionate correlation with the LS measured 3 days before and 3 months after the intervention (r = 0.41 & 0.44, p: 0.04 & 0.03, respectively). LSM drops significantly 3 months after intervention (from 51.62 ± 22 kPa to 28.80 ± 19.25 kPa (p: 0.001)). There is a significant improvement in LSM post-intervention among patients with moderate to severe fibrosis (METAVIR scores of ≥ F2 before intervention (p: 0.001).ConclusionsLSM in BCS patients reflects congestion rather than fibrosis stage. TE can be used for the short-term monitoring of patients with BCS following the endovascular intervention as a noninvasive tool.

Low discontinuity of care rate for adults with complex congenital heart disease: A single center's experience

BackgroundDiscontinuity of care between childhood and adulthood is an identified problem for those with congenital heart disease. ObjectiveThis study investigated our center's discontinuity of care rate during this transition period. MethodsThe study cohort included those post-Fontan performed in childhood; those post-pulmonary valve, mitral valve, or aortic valve replacements initially performed between birth and age 17 years; those post-atrial switch operations; and those with biventricular hearts and discordance of atrioventricular and ventriculoarterial connections. We included patients born between 1978 and 2000 and cared for at our center initially from a prenatal diagnosis, birth, infancy, or childhood. We defined discontinuity of care as lack of continuing care until a minimum of 20 years of age, after excluding those that died before 20 years old or had documented continuing care at another center. We also tabulated patients that underwent at least one adult invasive procedure during continuous care. ResultsWe identified 245 patients, of which 19 (7.8%) experienced discontinuity of care. Of the 226 in continuous care, 137 (60.6%) underwent 187 invasive procedures as adults: 36 cardiovascular surgeries, 82 surveillance cardiac catheterizations with or without transvenous liver biopsy, 32 interventional cardiac catheterizations, and 37 electrophysiology procedures with or without a pacemaker procedure. ConclusionWe found a low, 7.8% discontinuity of care rate for adults with complex congenital heart disease at our center. Further, for adults with complex congenital heart disease, most required additional invasive procedures as adults.

EUS-Guided versus Percutaneous Image-Guided Liver Biopsy: A Battle for Supremacy!

AbstractLiver biopsy has been the gold standard investigation for diagnosing and staging liver diseases. Image-guided percutaneous liver biopsy is a time-tested technique for obtaining the liver tissue in diffuse liver diseases. However, it is contraindicated in patients with ascites, altered mental status, skin infections, coagulopathy, and thrombocytopenia. It is associated with adverse events including postprocedure pain, bleeding, and pneumothorax. Transvenous liver biopsy can be performed in most cases with these contraindications, but it is an expensive technique and has its own inherent risks. Endoscopic ultrasound (EUS)-guided liver biopsy (EUS-LB) is a relatively new technique that has shown promising results and seems to have a potential of replacing percutaneous liver biopsy. In this news and views, we discuss the results of a randomized controlled trial (RCT) comparing EUS-guided and percutaneous techniques of liver biopsy. This RCT reported that percutaneous technique is superior in terms of diagnostic adequacy and total expenditure without any significant adverse effects compared with EUS-LB. EUS-LB is a promising technique that needs to be further explored in terms of appropriate situations in which it can be preferred over percutaneous or transvenous routes.

Fontan-associated liver disease and total cavopulmonary anatomical flow effectors.

We investigated a relationship between a composite index comprised of Fontan-circuit anatomical features and hepatic fibrosis scores from biopsy. We identified living extracardiac Fontan patients, ≥7 years old and ≥5 but <20 years postoperative, that underwent cardiac catheterization and transvenous liver biopsy between March 2012 and September 2020. We divided patients into anatomical groups and applied a risk score to each patient. We compared average anatomical risk scores with average hepatic total fibrosis scores by group. We identified 111 patients that met inclusion criteria. After excluding four patients, we assigned 107 to one of 12 anatomical variant groups (n ≥ 3). For the 107, the average age at liver biopsy was 14 ± 6 years old. Of the 107, 105 (98%) were New York Heart Association Class 1. We found average anatomical risk scores by group correlated with average total fibrosis scores by group (R = 0.8; p = .005). An average Fontan duration to biopsy of 10 ± 1 years was similar for all 12 anatomical groups. We found no other clinical variables, laboratory, or hemodynamic values that trended with anatomical risk scores or hepatic total fibrosis scores. In a cohort of relatively young, stable extracardiac Fontan patients, average composite anatomical risk scores strongly correlated with average hepatic total fibrosis scores by anatomical group. These findings suggest that some anatomical variants in extracardiac Fontan patients are associated with higher Fontan-associated liver disease (FALD)-related hepatic total fibrosis scores than others, despite similar Fontan durations.

Transjugular versus Transfemoral Transcaval Liver Biopsy: A Single-Center Experience in 500 Cases

PurposeTo compare the safety and efficacy of transfemoral transcaval liver biopsies (TFTC) with that of transjugular liver biopsies (TJLB) at a single tertiary-care institution. Materials and MethodsA retrospective review was performed of 500 consecutive transvenous liver biopsies between December 2010 and December 2018. The cases included 286 TFTC patients at a median age of 54 years old (interquartile range [IQR], 42–63 years of age), 37.4% were female; and 214 TJLB patients at a median age of 55 years old (IQR, 46–61 years of age), 45.4% female. Patient demographic and laboratory data and technical and histopathological success, fluoroscopy times, and complications were recorded. Comparative statistical analyses were performed using a 2-sample test or a Wilcoxon ranked sum test for continuous variables and a chi-square test or Fisher exact test for categorical variables when appropriate. ResultsTFTC and TJLB data are presented as: technical success rates of 99.3% (283 of 286) and 100% (214 of 214), respectively; histopathologic success rates of 96.5% (275 of 285) and 95.8% (205 of 214), respectively; and major complication rates of 1.4% (4 of 284) and 5.6% (12 of 214), respectively (P = .009). There were no hepatic injuries in the TFTC group, whereas the TJLB group included 6 significant hepatic injuries requiring intervention. Median fluoroscopic times were 5.5 minutes (IQR, 3.9–8.6 minutes) for TFTC and 8.1 minutes (IQR, 5.2–13.1) for TJLB (P < .001). ConclusionsIn this single-institution study, TFTC was associated with a lower major complication rate and lower fluoroscopy times than conventional TJLB with similar technical and histopathologic successes.

The Rate of Hepatic Fibrosis Progression in Patients Post-Fontan.

This investigation analyzed the rate of hepatic fibrosis progression in post-Fontan patients that underwent hepatic biopsy. The study cohort comprised post-Fontan patients that underwent cardiac catheterization and transvenous liver biopsy between March 2012 and September 2019. We identified 126 patients that met inclusion criteria. Of the 126, 27 (21%) had a lateral tunnel Fontan, and 99 (79%) had an extracardiac Fontan. For the 27 lateral tunnel Fontan patients, age at Fontan was 4 ± 2years, and for the 99 extracardiac Fontan patients age at Fontan was 4 ± 2years (p = 0.98). For the 27 lateral tunnel Fontan patients, the average total fibrosis score was 3.0 ± 1.5; and for the 99 extracardiac Fontan patients, the average total fibrosis was 2.7 ± 1.7 (p = 0.48). For the lateral tunnel Fontan patients, the average Fontan duration was 20 ± 6years; and for the 99 extracardiac Fontan patients, the average Fontan duration was 11 ± 5years (p < 0.001). For the 27 lateral tunnel Fontan patients, the average rate of fibrosis progression was 0.16 ± 0.10 total fibrosis score/year; and for the 99 extracardiac Fontan patients, the average rate of fibrosis progression was 0.30 ± 0.23 total fibrosis score/year (p < 0.001). In conclusion, our findings suggest that those with extracardiac Fontans have a faster rate of hepatic fibrosis progression than those with lateral tunnel Fontans. More extensive or multi-institutional studies will be needed to confirm these findings and define the clinical significance of discrepant rates of hepatic fibrosis in post-Fontan patients.

3:00 PM Abstract No. 199 Comparing transvenous liver biopsy techniques in congestive liver disease: which is more representative?

3:00 PM Abstract No. 199 Comparing transvenous liver biopsy techniques in congestive liver disease: which is more representative?

04:12 PM Abstract No. 81 Comparing transfemoral transcaval and transjugular transvenous core-needle liver biopsies in patients with Fontan-associated liver disease

04:12 PM Abstract No. 81 Comparing transfemoral transcaval and transjugular transvenous core-needle liver biopsies in patients with Fontan-associated liver disease

4:21 PM Abstract No. 370 Transfemoral transcaval core-needle liver biopsy: safety and efficacy in over 200 cases

To investigate the safety, efficacy, and outcomes of transfemoral transcaval (TFTC) core-needle liver biopsies. We previously published our results of the first 66 patients using TFTC as an alternative to transjugular liver biopsy, where hepatic tissue is directly obtained through the intrahepatic inferior vena cava via a femoral venous approach. In this retrospective study, the medical, surgical, and radiological records of patients who underwent transvenous liver biopsies at a single institution between February 2014 and August 2017 was performed. This is a follow-up study where we present the outcomes and complications of over 200 patients. Procedural complications were classified according to the Society of Interventional Radiology guidelines. 204 total TFTC liver biopsies (61.5% male; mean age 51.1 ± 15.5 years) accounted for 75.0% (204/272) of the transvenous liver biopsies. Technical success was achieved in 98.5% (201/204) of cases. Histopathologic diagnoses were made in 198 cases (97.1%). Fragmented or limited samples in which a pathological diagnosis was still made occurred in 6 cases (3.0%). Complications occurred in 4 cases (1.9%). There was one case with a small subhepatic hematoma, not requiring any transfusion and one case with delayed bleeding at the femoral puncture site requiring a blood transfusion that was successfully treated with a figure eight stitch. Venous pressure measurements were requested in 171 cases and were successfully obtained in all. TFTC core-needle liver biopsy is a safe and highly effective method of obtaining hepatic tissue samples and venous pressure measurements.

Transfemoral Transcaval Core-Needle Liver Biopsy: An Alternative to Transjugular Liver Biopsy

PurposeTo describe the technique and outcome of transfemoral transcaval (TFTC) core-needle liver biopsies. Materials and MethodsRetrospective chart review was performed on 121 patients who underwent transvenous liver biopsies at a single institution between February 2014 and July 2015, yielding 66 total TFTC liver biopsies for review (65.2% male; mean age, 53.2 y ± 15.0). From August 2014 through July 2015, TFTC biopsies accounted for 64 of 77 (83%) transvenous biopsies. Hepatic tissue was obtained directly through the intrahepatic inferior vena cava from a femoral venous approach. Procedural complications were classified according to Society of Interventional Radiology guidelines. ResultsOf the 66 biopsies, technical success was achieved in 64 cases (97.0%). Histopathologic diagnoses were made in 63 cases (95.5%). Fragmented or limited specimens in which a pathologic diagnosis was still made occurred in four cases (6.1%). Complications occurred in two cases (3.0%). Venous pressure measurements were requested in 60 cases, and all were successfully obtained. ConclusionsTFTC core-needle liver biopsies are feasible and safe as demonstrated in this series of patients.

Fontan hepatic fibrosis and pulmonary vascular development.

Fontan patients are at risk for hepatic fibrosis; however, risk factors are unclear. We performed a multivariate analysis in a small cohort of 14 patients (7-24years old, mean 15) with Fontan circulation,undergoing cardiac catheterization and transvenous liver biopsies, all demonstrating fibrosis. Wefound by stepwise regression analysis that the history of pulmonary atresia was a predictor of higher total hepatic fibrosis scores than a history of unobstructed pulmonary blood flow (p=0.002). Other variables including age, time from Fontan, hemodynamic measurements, and laboratory values were not predictiveoftotal fibrosis scores at p values <0.05. Hepatic fibrosis scores between those born with pulmonary atresia versus unrestricted pulmonary blood flow may reflect differences in pulmonary circulatory physiology, resulting from differences in pulmonary vascular development.

Hépatite alcoolique aiguë : prise en charge en 2011

Acute alcoholic hepatitis associates liver failure and jaundice in a context of chronic ethanol intoxication. It results from two mechanisms of ethanol-induced liver aggression: a dose-dependent toxicity and an inflammatory response. Diagnosis is based on clinical examination (assessing jaundice, fever, ascitis, malnutrition, hepatic encephalopathy, and/or tender liver) and laboratory tests (showing elevated aspartate aminotransferase > 2N with an aspartate aminotransferase-to-alanine aminotransferase ratio > 2, elevated white blood cell count, increased serum bilirubin, and/or increased international normalized ratio [INR]). Transvenous liver biopsy is useful to confirm the diagnosis. Several prognostic scores have been validated, including Maddrey, Glasgow, and MELD scores. Abstinence from ethanol is basically required. The current gold standard treatment includes corticosteroids. Pentoxifylline and enteral nutrition may be considered in case of uncontrolled infection. If refractoriness is assessed, salvage treatments remain to be defined.

Radiologic Imaging and Intervention for Gastrointestinal and Hepatic Complications of Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is an increasingly available treatment option for patients with various oncologic, hematologic, and immunologic diseases. Although HSCT can be curative for some diseases, complications associated with this treatment limit its success and applicability. Gastrointestinal graft-versus-host disease (GVHD) and hepatic veno-occlusive disease are unique and deadly complications of HSCT. These diseases can mimic other HSCT complications, such as infection, hemorrhage, and hepatotoxicity with cholestasis, but GVHD and veno-occlusive disease require specific treatment. Early treatment improves the probability of treatment success. For these reasons, timely and accurate diagnosis is essential. Abdominal imaging and intervention play an important role in the early, minimally invasive diagnosis and treatment of GVHD and veno-occlusive disease. Imaging findings tend to be nonspecific, but common findings that may guide further management or establish a diagnosis in the clinical setting have been defined. In cases where the diagnosis is unclear and liver biopsy is required, image-guided transvenous liver biopsy may be a safer and more practical option than the transcutaneous approach. Image-guided interventions, including intraarterial steroid-injection therapy in severe, systemic steroid-refractory GVHD and transjugular intrahepatic portosystemic shunt placement in veno-occlusive disease with portal hypertension, have shown some promise in small, uncontrolled series. Larger, controlled studies are needed to define the role of these invasive procedures in this patient population.

Nodular regenerative hyperplasia of liver as a consequence of ART

Nodular regenerative hyperplasia of liver as a consequence of ART

Value of carbon dioxide wedged venography and transvenous liver biopsy in the definitive diagnosis of Abernethy malformation

We report a 25-year-old man who presented with congenital absence of the portal vein, or Abernethy malformation, a rare congenital disorder in which the mesenteric and splenic venous drainages bypass the liver and directly drain into the inferior vena cava through an extrahepatic portosystemic shunt. Magnetic resonance imaging, which showed multiple nodular lesions in both liver lobes that were associated with an absence of intrahepatic portal venous branches, strongly suggested the diagnosis of the Abernethy malformation. Carbon dioxide wedged venography and transvenous liver biopsy, which were performed in the same session by a right jugular approach, confirmed these findings. This technique can be considered a valuable alternative diagnostic tool to catheter arteriography and percutaneous transhepatic liver biopsy.

Chemotherapy Dosing with Elevated Liver Function Test Results in Acute Leukemia

To report a case of massive blast infiltration of the liver by acute lymphoblastic leukemia (ALL) manifested by worsening liver function test (LFT) results and concern over how to dose chemotherapy in this patient. A 36-year-old male presenting with productive cough, abdominal pain, and lower back pain was diagnosed with pre-B cell ALL. Of note, the patient developed worsening LFT results within the first few days of diagnosis. Because of concern over increasing liver dysfunction and the need to administer vincristine and daunorubicin with induction therapy, a transvenous liver biopsy was performed, revealing massive lymphoblast infiltration. A short course of prednisone was given to determine whether the LFT abnormalities would reverse with treatment. Once a downward trend in the abnormalities was noted, full-dose induction chemotherapy was administered. It is important to discern the cause of elevated LFT values in patients with acute leukemia who require induction chemotherapy, as this may affect treatment decisions and patient outcomes.

SIR 2005 Annual Meeting Film Panel Case: Inferior Mesenteric Artery–to–Inferior Mesenteric Vein Fistulous Connection

A 56-year-old man was admitted to the hospital because of lower gastrointestinal bleeding manifested by black, tarry stool. Medical history and physical examination were noncontributory; he had no history of alcohol or drug abuse. Laboratory findings included a hematocrit of 26.2% and a platelet count of 166,000/ L. International Normalized Ratio and aspartate aminotransferase, alanine aminotransferase, albumin, and bilirubin levels were normal. Serologic examinations were negative for hepatitis. Large esophageal varices were seen on upper endoscopy. A transvenous liver biopsy was performed, which demonstrated nodular regenerative hyperplasia. Arterial portography, hepatic venography, cavography, and venous pressures were normal. The corrected sinusoidal pressure (wedged minus free hepatic venous pressure) was 11 mm Hg. However, subsequent direct portography performed via a transjugular approach demonstrated a portal vein–to–hepatic vein gradient of 30 mm Hg. A surgical shunt was performed to manage the gastrointestinal bleeding. Intraoperatively, the inferior mesenteric vein was noted to be quite large and to interfere with mobilization of the left renal vein; the inferior mesenteric vein was divided and the limb in communication with the splenic vein was sewn to the left renal vein. Postoperative magnetic resonance (MR) angiography was performed (Fig 1) because the shunt could not be visualized on surveillance ultrasonography. Because of the findings, inferior mesenteric arteriography (Fig 2) was performed.

Transvenous Liver Biopsy via the Femoral Vein

AIM: To study the safety, effectiveness and diagnostic value of transvenous forceps biopsy of the liver in 54 patients with coagulopathy, gross ascites or morbid obesity and suspected liver disease in whom percutaneous liver biopsy was contraindicated. MATERIAL AND METHODS: Forceps biopsy of the liver via the femoral vein was attempted in 54 adult patients with advanced liver disease of unknown aetiology who had coagulation disorders (41 cases), gross ascites (11 cases) or morbid obesity (two cases). In each patient two to six biopsies (average four) were taken using a radial jaw forceps inserted via the right or left femoral vein. RESULTS: The procedure was successful in 53 cases. Hepatic vein catheterization failed in one patient. Adequate liver tissue for diagnosis was obtained in 84% of cases. One patient developed delayed haemorrhage at 12 h from a capsular leak that was undetected during the biopsy procedure. This patient required blood transfusions and laparotomy to control bleeding. There were no deaths in the 53 patients studied. Transient minor chest and shoulder pain was encountered during sheath insertion into a hepatic vein in 23 patients. Three patients developed a femoral vein haematoma, which resolved with conservative treatment. CONCLUSION: Transvenous liver biopsy via the femoral vein is another safe, effective, simple alternative technique of biopsy when the percutaneous route is contraindicated.