Management of Bleeding after Percutaneous Transhepatic Cholangiography or Transhepatic Biliary Drain Placement

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Bleeding complications occur in 2 to 3% of percutaneous transhepatic biliary drains. These complications include: hemothorax, hemoperitoneum, subcapsular hepatic bleeding, hemobilia, melena, and bleeding from the percutaneous biliary drain. The bleeding sites can be classified into (1) perihepatic bleed sites (hemothorax, hemoperitoneum, subcapsular hepatic hematoma), (2) gastrointestinal bleeding (hemobilia and/or melena), and (3) bleeding from the percutaenous biliary drain itself, which is the most common clinical presentation. There are several bleeding sources. These include skin-bleeds, intercostal artery, portal vein, hepatic vein, and the hepatic artery. There are a variety of maneuvers that can be utilized in the management of bleeding percutaneous biliary drains. These include tractography, angiography, tract embolization, arterial embolization, and tract site changes. This article proposes a protocol for approaching bleeding complications after percutaneous biliary drain placement and details the diagnostic and therapeutic procedures in the management of these bleeding complications.

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Reducing the Risk of Hemorrhagic Complications

When planning transhepatic needle access in the biliary tract, particularly with the intention of placing a biliary drain, the operator should attempt to avoid the central bile ducts as much as possible (Fig. 3). Central bile ducts are accompanied by larger and more crowded blood vessels and the likelihood of transgressing an artery or large vein is higher.2 In addition, the operator should pass the definitive access needle and subsequently the PBD above the ribs to avoid the intercostal

Bedside Measures of Bleeding PBDs Including Local Control of Bleeding

At bedside the first thing that should be assessed is the patient's stability. The patients' vital signs should be compared with their baseline. Some relative hypotension can be expected after moderate sedation. In addition, the patients' blood should be typed and crossed ready for blood transfusion should the hematocrit be low. The target should be a hematocrit above 30%. Second, the actual site of the bleeding, if apparent, should be assessed. The bleeding could be through the PBD and into

Transhepatic Tractography and Transhepatic Procedures

Some operators consider a transhepatic tractogram as the first imaging investigation based on that the likelihood that a venous injury is higher than the likelihood of an arterial injury particularly in a stable patient. Other operators would go directly to an arteriogram (see below) to rule out a significant injury that can potentially be dealt with decisively by endoluminal means.2 Furthermore, having contrast in the biliary tract may obscure the arterial injury if a subsequent arteriogram is

Hepatic Arteriography and Transcatheter Embolization

Once an arterial injury is suspected from the transhepatic tractogram, a hepatic arteriogram is warranted. Some operators may perform an arteriogram first, especially if the patient is unstable. Hepatic arteriograms are performed most commonly from a femoral approach. The celiac axis is catheterized using standard 5-French catheters such as SOS or C-2 Cobra catheters. If no bleeding is identified, selective hepatic arteriography is required using microcatheters. Selective angiograms should be

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