Hepatobiliary · IR Playbook

Percutaneous transhepatic biliary drainage (PTBD)

Percutaneous transhepatic biliary drainage is image-guided decompression of an obstructed or infected biliary system via a transhepatic puncture into a bile duct, followed by catheter placement to divert bile externally or internally into the duodenum. It is most commonly performed for malignant hilar or distal biliary obstruction, benign strictures, or cholangitis when endoscopic retrograde cholangiopancreatography fails or is not feasible. Technical success exceeds 95 percent in dilated systems, with major complication rates of roughly 3 to 10 percent including hemobilia, sepsis, and bile leak.

Learning objectives

• Differentiate indications for PTBD versus ERCP in obstructive jaundice
• Describe the two-step technique of biliary access and catheter placement
• List the classification and clinical relevance of bile duct injury and stricture patterns
• Recognize and manage major complications including cholangitis, hemobilia, and bile leak
• Plan the approach to convert external to internal-external drainage and eventual internalization

Indications

• Malignant biliary obstruction with failed or inaccessible ERCP, such as hilar cholangiocarcinoma or pancreatic head carcinoma
• Acute cholangitis with biliary obstruction unresponsive to antibiotics, when endoscopic drainage fails
• Benign biliary strictures including post-surgical or post-transplant anastomotic strictures
• Preoperative biliary decompression prior to major hepatobiliary resection in selected jaundiced patients
• Access for percutaneous biliary interventions such as stone extraction, biopsy, or stricture dilation
• Bile duct injury requiring diversion, for example post-cholecystectomy leak

Absolute contraindications

• Uncorrectable severe coagulopathy or thrombocytopenia unresponsive to correction
• Hemodynamically unstable patient not fit for the procedure

Relative contraindications

• Massive ascites, which increases risk of catheter dislodgement and leak, correctable by paracentesis or tract embolization
• Multiple hepatic cysts or echinococcal disease along the needle path
• Non-dilated intrahepatic ducts, which increase technical difficulty
• Active untreated coagulopathy with INR above 1.5 or platelets below 50000 per microliter, correctable prior to procedure

Equipment

• 21 G Chiba needle for initial cholangiogram
• 18 G one-part or two-part access needle for duct puncture
• 0.018 inch mandril wire and micropuncture transition system
• 0.035 inch stiff hydrophilic guidewire, for example Glidewire
• 0.035 inch stiff exchange guidewire, for example Amplatz Super Stiff
• 5 Fr micropuncture sheath
• 5 Fr Kumpe or similar angled catheter for ductal navigation
• 8 to 10.2 Fr locking pigtail biliary drainage catheter
• Dilator set 6 to 10 Fr for tract dilation
• Non-ionic iodinated contrast diluted 50 percent with saline
• Drainage bag and connecting tubing

Procedure steps

1. Position the patient supine with the right arm elevated above the head for a right-sided approach. Prep and drape the right upper quadrant or subxiphoid region in sterile fashion, and administer local anesthesia at the planned entry site.Pearl: Have the patient practice suspended respiration or quiet breathing before starting to improve puncture accuracy.
2. Under ultrasound guidance, advance a 21 G or 18 G needle into a peripheral dilated bile duct in a single breath-hold, aiming parallel to the expected course of the duct.
3. Aspirate bile to confirm intraductal position, then inject diluted contrast slowly under fluoroscopy to opacify the biliary tree without overdistending an infected system.Pearl: In suspected cholangitis, aspirate as much bile as possible before contrast injection to avoid precipitating septic shower.
4. Advance a 0.018 inch guidewire through the needle into the duct, then exchange for a 5 Fr micropuncture sheath. Upsize over a stiffer 0.035 inch guidewire for subsequent catheter manipulation.
5. Using a angled catheter such as a Kumpe and hydrophilic guidewire, negotiate the wire through the stricture or obstruction into the duodenum whenever feasible.Pearl: Crossing the obstruction on the first setting allows internal-external drainage, improving physiology and reducing catheter-related complications.
6. Once the duodenum is reached, exchange the hydrophilic wire for a stiff 0.035 inch exchange wire to provide a stable rail for catheter placement.
7. Dilate the transhepatic tract sequentially using fascial dilators up to 1 to 2 Fr larger than the intended drainage catheter.
8. Advance an 8 to 10.2 Fr locking pigtail catheter over the wire, positioning the pigtail loop in the duodenum for internal-external drainage, or coiled in the biliary system above the obstruction if the stricture cannot be crossed.Pearl: If the obstruction cannot be crossed at the initial setting, place an external drainage catheter and plan a repeat attempt in 48 to 72 hours once ductal decompression and inflammation improve.
9. Confirm catheter position and loop formation with contrast injection and fluoroscopy, then secure the catheter to the skin with a retention disc or suture and connect to a drainage bag.
10. Obtain final fluoroscopic images documenting catheter position, contrast flow across the obstruction if internal-external, and absence of extravasation.

Complications

• Cholangitis and sepsis, approximately 2 to 10 percent
• Hemobilia, approximately 2 to 4 percent clinically significant
• Bile leak and peritonitis, approximately 1 to 3 percent
• Pneumothorax or hemothorax, particularly with high intercostal punctures

Exam pearls

• PTBD is generally reserved for cases where ERCP fails, is contraindicated, or biliary anatomy is surgically altered such as Roux-en-Y
• Right-sided approach uses an intercostal or subcostal route in the midaxillary line targeting a peripheral duct; left-sided approach is subxiphoid
• Internal-external drainage is preferred over pure external drainage whenever the obstruction can be crossed
• Hemobilia after PTBD warrants angiography and embolization if a pseudoaneurysm or arteriobiliary fistula is identified, not simply catheter manipulation
• Routine catheter exchange interval is typically every 6 to 8 weeks to prevent encrustation and blockage
• A clamping trial is used before catheter removal to confirm adequate internal bile drainage into the duodenum

Viva questions

Why is a peripheral duct preferred over a central duct for initial puncture in PTBD?

Peripheral ducts are farther from major hilar vascular structures, reducing the risk of arterial or portal venous injury, and provide a longer, more stable transhepatic tract for catheter fixation.

What is the difference between external and internal-external biliary drainage, and why is internal-external preferred when feasible?

External drainage diverts all bile outside the body via a catheter proximal to the obstruction, while internal-external drainage has side holes spanning the obstruction so bile can also flow into the duodenum. Internal-external drainage preserves enterohepatic bile salt circulation, improves nutrition and coagulation, and reduces fluid and electrolyte loss.

A patient develops hematemesis and hemobilia three days after PTBD. What is your next step?

First confirm catheter patency and hemodynamic stability, then perform a catheter cholangiogram or CT angiography to look for a pseudoaneurysm or arteriobiliary fistula, followed by hepatic angiography with selective embolization if a bleeding source is identified.

What cutoffs for INR and platelet count are typically required before PTBD?

An INR of 1.5 or less and a platelet count of at least 50000 per microliter are generally required, correcting with fresh frozen plasma, vitamin K, or platelet transfusion as needed before the procedure.

In a patient with Bismuth type IV hilar cholangiocarcinoma, why might bilateral PTBD be preferred over unilateral drainage?

Bismuth type IV involves both right and left hepatic duct systems with separation at the confluence, so unilateral drainage may leave a large volume of undrained, potentially infected liver; bilateral drainage maximizes the functional liver volume decompressed and reduces the risk of cholangitis in the undrained segment.

Why should contrast injection be minimized during the initial cholangiogram in a patient with suspected cholangitis?

Injecting contrast into an obstructed, infected biliary system under pressure can force bacteria and endotoxin into the bloodstream, precipitating bacteremia and septic shock; bile should be aspirated first and contrast injected slowly and sparingly.

References