Basic steps required to perform percutaneous transhepatic biliary drainage
If indicated by the diagnostic percutaneous transhepatic cholangiogram and clinical symptoms, a wire can be placed via the accessing needle into the biliary tree, followed by tract dilation and biliary drainage catheter placement. This is called the “one-stick” method. If the initial puncture was directed into a central duct, a “two-stick” technique may be used. Central duct punctures are not ideal because the risk of injuring a major hepatic vessel is significant. A second needle may be placed into an appropriate more peripheral duct, and the tract is subsequently dilated and used for access. The ideal access site is an opacified peripheral duct that can be easily accessed under fluoroscopic guidance. Aside from a peripheral location, the duct’s path should course through an angle that is gentle enough to allow a catheter to be advanced into the small bowel without extreme angulation or kinking. After the second access is obtained, the first needle can be removed. If left-sided biliary drainage is being performed, the needle is passed into the liver from a left subxiphoid approach.