Percutaneous Transhepatic Cholangiogram (PTC)

Percutaneous transhepatic cholangiogram (PTC), also known as biliary drainage, is an interventional radiological procedure used to evaluate and address abnormalities of the biliary system, which includes the bile ducts and gallbladder. These techniques involve the percutaneous insertion of a needle or catheter into the liver parenchyma to access the biliary tree.

During a PTC procedure, the skin is punctured, and a needle is advanced under ultrasound and fluoroscopic guidance into the liver, specifically targeting a bile duct. A contrast agent is then injected through the needle, allowing for visualization of the biliary system on the angiography system. This imaging technique provides detailed information about the anatomy and any potential obstructions or strictures in the bile ducts.

Following the cholangiogram, therapeutic interventions such as biliary drainage may be performed. Biliary drainage involves the placement of a catheter or stent into the obstructed or narrowed bile duct to restore or improve bile flow. The drainage catheter is positioned across the stricture or obstruction and secured in place, allowing bile to bypass the obstruction and drain externally or into the intestine.

PTC is indicated in various conditions, including biliary strictures, choledocholithiasis (gallstones in the bile ducts), or obstructive jaundice. These procedures aim to relieve biliary obstruction, alleviate symptoms such as jaundice and abdominal pain, and promote the resolution of underlying biliary pathologies.

A&I Protocol

Patient is usually positioned supine on the angiography table, with the right arm extended laterally and supported with an armboard and pillow, or with the patient slightly obliqued (right side up) and arms by their side. This depends on the biliary tree access, and if left, right, or bilateral punctures are required.

Seldinger technique using a 21G diagnostic needle and supporting 0.038" guidewire are used to gain access into the left or right biliary tree under ultrasound guidance.
A luer-slip syringe and extension system are connected when bile exits the hub of the needle.
X-ray using the angiography system is used to confirm the position of the needle within the biliary tree and then using contrast media injection with fluoroscopy.
The contrast media is used to perform a cholangiogram image the biliary tree and towards the duodenum (exiting the ampulla of vater), and can determine the site/s of biliary strictures.
A 7F 23cm sheath is introduced over a long 180 cm guidewire.
For a PTC, the procedure is completed by inserting a specific biliary drainage catheter, usually 10-12F in size. This is connected to an external drainage bag.
Further intervention can be performed with angioplasty of the bile duct, by measuring the diameter of the bile duct and ballooning the stricture. Access through the stricture is done using a guidewire or hydrophilic guidewire and a Bern-shaped catheter. Once the stricture is crossed, a high pressure 0.035" angioplasty balloon is inflated.
Additional intervention can involve the insertion of either a covered or uncovered biliary stent which is deployed through the 7F sheath and is positioned from the biliary tree towards the common bile duct and duodenum. Depending on the size of the stent required, the sheath may need to be exchanged to a larger French size.
Following the procedure, a drainage bag is secured from the biliary drainage catheter and is allowed to free-flow to decompress the affected liver lobe/s.

"Through the mesh" biliary stenting technique:

If a dual biliary stenting is required to drain the left and right biliary tree of the liver, a "through the mesh" technique is employed.
With bilateral access from the left and right lobe, and large introducer sheaths and stiff wire in place. The stent delivery system is then advanced over the wire. Stent deployment on the right side is achieved with balloon dilatation.
Following the deployment of the first stent, a stiff wire and Bern-shaped catheter are used to cannulate in between the struts of the stent from the contralateral side.
Once through, the second stent delivery system is advanced over the wire and deployed with balloon dilatation.
The resultant angiography image is a "Y-shaped" structure with the left and right stents within the left and right biliary tree and the converging stents in the common bile duct towards the ampulla of vatar (see image below).

Fluoroscopy of a PTC procedure pre- and post-stenting.

"Through the mesh" biliary stenting technique.

References

Covey AM, Brown KT. Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol. 2008 Mar;11(1):14–20.
Hassan Z, Gadour E. Percutaneous transhepatic cholangiography vs endoscopic ultrasound-guided biliary drainage: A systematic review. World J Gastroenterol. 2022 Jul 21;28(27):3514–23.
Sato T, Nakai Y, Fujishiro M. Current endoscopic approaches to biliary strictures. Curr Opin Gastroenterol. 2022 Sep 1;38(5):450–60.
Yee AC, Ho CS. Percutaneous transhepatic biliary drainage: a review. Crit Rev Diagn Imaging. 1990;30(3):247–79.
Kokas B, Szijártó A, Farkas N, Ujváry M, Móri S, Kalocsai A, et al. Percutaneous transhepatic drainage is safe and effective in biliary obstruction-A single-center experience of 599 patients. PLoS One. 2021;16(11):e0260223.