Percutaneous retrograde access of the common bile duct to perform completely percutaneous biliary rendezvous procedures

Monday, March 6, 2023

12:00 PM – 1:00 PM

Location: Phoenix Convention Center, North Ballroom 120 D

Poster Presenter(s)

Daniel M. DePietro, MD

Resident
Perelman School of Medicine at the University of Pennsylvania

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

Richard D. Shlansky-Goldberg, MD (he/him/his)

Professor
Perelman School of Medicine at the University of Pennsylvania

Disclosure(s):

Daniel M. DePietro, MD: No financial relationships to disclose

Richard D. Shlansky-Goldberg, MD: No financial relationships to disclose

Purpose: Direct retrograde percutaneous catheter access of the common bile duct (CBD) to facilitate crossing a biliary obstruction is generally contraindicated due to the fear of arterial injury and biliary leak. Endoscopic retrograde cholangiopancreatography (ERCP) can be used as part of a “rendezvous procedure’ but is often difficult due to logical issues such as timing and patient positioning or post-surgical gastrointestinal/biliary anatomy. This study evaluates direct percutaneous retrograde CBD catheter access in performing completely percutaneous rendezvous procedures.

Materials and Methods: Eight patients (5F:3M; mean age 59 ± 10 years) underwent percutaneous retrograde CBD access from 2017-2022. The CBD was punctured under fluoroscopic guidance using a 21 gauge needle, targeting a CBD opacified by contrast injected via another access (n=4), a plastic (n=2) or metal (n=1) stent, or an internal/external drain (n=1). Retrograde access was obtained using a microwire, microcatheter and a microsnare for targeting a peripheral duct or to capture an antegrade wire to cross a stenosis/obstruction that could not be crossed in an antegrade fashion. One case was performed to create a neo-anastomosis via gunsight technique with two microsnares on both sides of a malignant obstruction. Data regarding patient history, procedural details, and outcomes were reviewed.

Results: Indications for drainage included malignant biliary obstruction (n=3), iatrogenic biliary injury/leak (n=3), metal stent occlusion (n=1), and biliary cast syndrome after liver transplant (n=1). The percutaneous rendezvous procedure was the index percutaneous biliary intervention in 63% (n=5) and performed after the index procedure in 37% (n=3; median=54 days, range 7-107 days) to internalize an external drain. The target lesion was crossed successfully via the initial retrograde CBD access in 88% of patients (n=7). In the remaining patient, the retrograde CBD access facilitated crossing of the lesion via antegrade biliary access as a result of improved biliary tree opacification and anatomic delineation. An I/E drain was placed in 88% of patients (n=7). An external drain was placed in 1 patient with a duodenal stump leak. Median follow-up was 110 days (range 3-214 days). There were no major complications including hepatic artery injury or biliary leak at the CBD access site.

Conclusion: Percutaneous retrograde CBD access is feasible and safe, enabling successful biliary rendezvous procedures to be performed completely percutaneously without the need for concurrent ERCP.