Residency · Residency · Interventional Radiology

Percutaneous Transhepatic Cholangiography and Biliary Drainage

Overview

Percutaneous transhepatic cholangiography (PTC) provides direct opacification of the biliary tree via a needle placed through the liver parenchyma. Percutaneous transhepatic biliary drainage (PTBD) extends PTC by placing a catheter for decompression of obstructed bile ducts. Primary indications: malignant biliary obstruction, failed ERCP, post-surgical biliary complications. Performed under fluoroscopic guidance with moderate sedation or general anesthesia.

Indications

Biliary Obstruction

Malignant obstruction: cholangiocarcinoma, pancreatic head adenocarcinoma, hepatic hilum metastases, gallbladder carcinoma. Benign strictures: post-surgical (hepaticojejunostomy), chronic pancreatitis, PSC. Failed or inaccessible ERCP (surgically altered anatomy: Roux-en-Y, Whipple). Biliary sepsis requiring emergent decompression. Preoperative biliary decompression (controversial — see below).

Diagnostic PTC

Mapping of biliary anatomy prior to surgery or intervention. Evaluation of biliary stricture morphology and extent (Bismuth-Corlette classification for hilar cholangiocarcinoma). Bile sampling for cytology or culture. Cholangioscopy access.

Biliary Interventions via PTC Access

Internal/external drain placement. Biliary stenting (plastic or metallic). Stricture dilation (balloon cholangioplasty). Stone extraction. Biliary biopsy / brush cytology.

Anatomy

Biliary Anatomy

Right hepatic duct: anterior sectoral duct (segments V, VIII) and posterior sectoral duct (segments VI, VII). Left hepatic duct: drains segments II, III, IV; longer extrahepatic course (advantage for access). Common hepatic duct → common bile duct (after cystic duct junction) → ampulla of Vater. Variant anatomy in ~30%: trifurcation, low insertion of right posterior duct, aberrant ducts.

Access Planning

Right-sided access: intercostal approach (typically 8th-10th intercostal space, mid-axillary line). Targets right posterior sectoral duct (segment VI/VII). Advantage: most common, largest target, ergonomic catheter course to CBD. Risk: pleural transgression (intercostal approach). Left-sided access: subxiphoid/epigastric approach. Targets segment II or III duct. Advantage: avoids pleura, better for hilar/left-sided lesions. More difficult catheter course to CBD; prone to kinking. Choice depends on site of obstruction, biliary anatomy, and planned intervention.

<image>Fluoroscopic percutaneous transhepatic cholangiogram showing dilated intrahepatic bile ducts with a hilar stricture and an internal/external biliary drain traversing the obstruction</image>

Technique

Pre-Procedural Preparation

Review cross-sectional imaging (CT/MRI/MRCP) for ductal dilation, level of obstruction, vascular anatomy, and ascites. Correct coagulopathy: INR ≤1.5, platelets ≥50,000. Administer prophylactic antibiotics (piperacillin-tazobactam or fluoroquinolone + metronidazole). NPO status; IV hydration. Informed consent including risks of bleeding, sepsis, and bile leak.

PTC Needle Access

Patient supine; right side elevated for right-sided access. Ultrasound used to identify dilated ducts and plan entry site (avoiding gallbladder, colon, pleura). 21-22 gauge Chiba needle advanced under fluoroscopic guidance toward the expected duct location. Stylet removed; contrast injected slowly while withdrawing needle until bile duct opacified. Fluoroscopic cholangiogram obtained to map the biliary tree. In non-dilated systems: multiple passes may be needed; success rate lower (~60-70% vs >95% for dilated systems).

Biliary Drainage Catheter Placement

Once duct accessed, a 0.018" wire advanced into the duct. Transition to 0.035" system via coaxial dilators or AccuStick system. Seldinger technique to upsize access tract. Catheter advanced over wire: External drainage: catheter tip in the biliary tree proximal to obstruction, drainage to external bag. Internal/external drainage: catheter traverses the obstruction into the duodenum; side holes above and below obstruction. Internal/external preferred when technically feasible (physiologic bile drainage, electrolyte preservation). Drain secured to skin; pigtail locked in duodenum or proximal bile duct. Typical initial drain size: 8-10 Fr; upsized later if needed for stent placement (10-12 Fr).

Biliary Access Tips

Target a peripheral duct — central puncture risks portal vein/hepatic artery injury. Aim for a duct that provides a straight-line course to the obstruction. Avoid the gallbladder fossa and caudate lobe ducts. If initial access is suboptimal, can redirect wire with angled catheters and hydrophilic wires. For hilar obstruction: may need bilateral access (right + left) to drain both systems.

<image>Diagram illustrating right-sided percutaneous biliary access showing the Chiba needle entering a dilated peripheral bile duct with subsequent wire and catheter advancement through the obstruction into the duodenum</image>

Drain Management

Initial Care

Drain capped to external bag initially; monitor output. Normal output: 200-500 mL/day (reflects bile production). Sudden increase: possible duodenal erosion or dislodgement. Sudden decrease: obstruction, kinking, dislodgement, or resolution of obstruction. Flush drain with 10 mL saline twice daily to maintain patency.

Capping Trial

For internal/external drains: cap the external port after confirmation of internal drainage. If patient tolerates capping (no pain, fever, or jaundice) → drain functioning internally. If intolerant: uncap and reassess for obstruction or malposition.

Drain Exchanges

Routine exchanges every 8-12 weeks to prevent encrustation and occlusion. Over-the-wire exchange with cholangiogram to assess for stent placement candidacy. Upsize tract gradually if planning metallic stent placement.

Conversion to Internal Stent

Once tract matures (7-14 days), can deploy internal metallic stent. Drain removed after stent placement and confirmation of adequate drainage. Obviates need for external drain management.

PTC vs. ERCP

When to Choose PTC over ERCP

Failed ERCP (inability to cannulate, failed stent placement). Surgically altered anatomy (Roux-en-Y, Whipple) making ERCP inaccessible. Proximal/hilar obstruction (Bismuth III-IV) — PTC provides better access. Need for bilateral drainage in hilar tumors. Hepaticojejunostomy strictures.

When ERCP is Preferred

Distal CBD obstruction (pancreatic head mass). Stone disease with intact papilla. Benign ampullary pathology. Avoids hepatic parenchymal puncture and its risks.

Controversy: PTC vs. ERCP for Distal Biliary Obstruction

ERCP is first-line for distal CBD obstruction by most guidelines. Some centers argue PTC with antegrade stenting has advantages for certain distal strictures. Combined rendezvous technique: PTC wire passed antegrade through obstruction, retrieved at duodenoscope, allowing retrograde stent placement.

<image>Comparison of external biliary drain, internal/external biliary drain, and internal metallic biliary stent configurations with their respective drainage pathways</image>

Complications

Common

Pain at access site. Transient bacteremia/fever (rigors in up to 20-30% despite antibiotics). Bile leak around catheter (usually self-limited, managed with larger drain or skin suture). Drain dislodgement or occlusion.

Uncommon / Serious

Sepsis/cholangitis (2-10%): most serious complication; can be fatal. Risk increased when opacifying obstructed, infected ducts. Minimize contrast injection volume; aspirate bile before injecting. Decompress quickly once access obtained. Hemorrhage: Arterial injury (hepatic artery branches): 2-5%. Hemobilia: arterial-biliary fistula presenting with GI bleeding, jaundice, biliary colic (Quincke triad). Portal vein injury: usually self-limited. Managed by tract embolization or hepatic artery embolization. Pleural transgression: pneumothorax, bilothorax, empyema (right-sided access). Bile peritonitis from bile leak. Pancreatitis (from guidewire/catheter manipulation at ampulla). Tumor seeding along percutaneous tract (rare).

Clinical Pearls

Always give antibiotics before PTC — an infected, obstructed biliary system under pressure can cause fatal sepsis within hours. Minimize contrast injection into obstructed systems — inject only enough to define anatomy, then decompress immediately. Left-sided access is underutilized; it avoids pleural transgression and provides excellent access for hilar and left-sided lesions. When both right and left systems are obstructed (Bismuth III/IV), drain the most symptomatic or infected side first, then stage bilateral drainage. A sudden drop in biliary drain output should prompt urgent evaluation — the drain may be kinked, displaced, or obstructed. Hemobilia after PTC (Quincke triad: RUQ pain, jaundice, GI bleed) should prompt CT angiography and possible hepatic artery embolization. Tract maturation takes 7-14 days; avoid removing or exchanging the drain within this period unless absolutely necessary. For patients with malignant obstruction and limited life expectancy, an internal metallic stent should be placed as soon as feasible to eliminate external drain burden.

References

• Stable JN, et al. Percutaneous Transhepatic Biliary Drainage: Results, Complications, and Factors Influencing Success. Radiology. 2022;302(2):271-280.
• Saad WE, Wallace MJ, et al. Quality Improvement Guidelines for Percutaneous Transhepatic Cholangiography, Biliary Drainage, and Percutaneous Cholecystostomy. J Vasc Interv Radiol. 2010;21(6):789-795.
• Weber A, et al. Endoscopic vs. Percutaneous Transhepatic Biliary Drainage in Malignant Hilar Obstruction. Gastrointest Endosc. 2009;70(1):53-62.
• Covey AM, Brown KT. Percutaneous Transhepatic Biliary Drainage. Tech Vasc Interv Radiol. 2008;11(1):14-20.
• Stable JN, Lorenz JM. Biliary Interventions. In: Defined IR Procedures. Elsevier; 2021.
• Stable SIR Quality Improvement Guidelines for Percutaneous Biliary Interventions. J Vasc Interv Radiol. 2016;27(3):408-411.

Read this lecture as Markdown