Downloaded from www.ajronline.org by 163.27.215.117 on 11/03/15 from IP address 163.27.215.117. Copyright ARRS.

For personal use only; all rights reserved

Original Report
Sang H. Lee1
Seong T. Hahn1
Single-Wall Puncture:
Hyung J. Hahn2 A New Technique for Percutaneous
Kyung J. Cho3
Transhepatic Biliary Drainage
OBJECTIVE. The purpose of our study is to evaluate the safety and utility of a new sin-
gle-wall puncture technique for percutaneous transhepatic biliary drainage in comparison
with the conventional double-wall puncture technique.
CONCLUSION. Our results suggest that the single-wall puncture technique is a useful
method for percutaneous transhepatic biliary drainage and may be safer than the conventional
double-wall puncture technique.

Received January 27, 2003; accepted after revision
March 20, 2003.
1 associated with the double-wall puncture
Department of Radiology, St. Mary’s Hospital,
The Catholic University of Korea, #62, Youido-dong,
Yongdungpo-gu, Seoul 150-010, Korea. Address
correspondence to S. T. Hahn (sthahn@cmc.cuk.ac.kr).
2
College of Medicine, Konkuk University, #322,
Danwol-dong, Chungju 380-701, Korea.
3
Department of Radiology, University of Michigan Hospital,
1500 E. Medical Center Dr., Ann Arbor, MI 48109-0030.
AJR 2003;181:717–719
0361–803X/03/1813–717
© American Roentgen Ray Society
P
ercutaneous transhepatic biliary
drainage has played an important
role in the treatment of obstruc-
tive disease of the bile duct [1, 2]. Typically,
more than one needle puncture is needed for
adequate catheter positioning in biliary
drainage. Therefore, percutaneous transhe-
patic biliary drainage carries the risk of hem-
orrhagic complications for many patients.
Risk factors for hemorrhagic complications
after percutaneous transhepatic biliary drain-
age include puncturing of adjacent vessels
and ducts, trauma by tract dilatation, coagul-
opathy, and so forth. Many interventional ra-
diologists use the standard double-wall
puncture technique, in which the needle may
traverse other ducts or vessels, even when the
target duct is punctured successfully. To re-
duce the risk of hemorrhagic complications
technique, we tested a new single-wall punc-
ture technique. This new technique is a
method of ductal puncture that could reason-
ably be expected to reduce the risk of unde-
sirable vessel puncture by using a forward
approach, in comparison to the pullback ap-
proach used with double-wall puncture. The
purpose of this prospective study was to assess
the safety and efficiency of the single-wall
puncture technique by comparing several of its
parameters with those of its conventional dou-
ble-wall counterpart.
Subjects and Methods
Thirty-nine consecutive patients (23 men and 16
women; age range, 40–86 years) with biliary ob-
struction underwent percutaneous transhepatic bil-
iary drainage during a recent 11-month period.
Patients who had repeated percutaneous transhepatic
biliary drainage during this period were not included
in this study. The underlying causes of disease were
cholangiocarcinoma in 19 patients (49%), pancreas
head carcinoma in 17 patients (44%), and stone dis-
ease in three patients (8%). All patients were pre-
medicated with an intramuscular injection of 25 mg
of pethidine hydrochloride (Demerol, Keuk Dong
Pharmacy, Inchon, Korea) approximately 30 min be-
fore the procedure.
The study patients were randomly classified into
two groups by admission date: those on whom per-
cutaneous transhepatic biliary drainage was per-
formed with the single-wall puncture technique
were admitted during the first 6 months (group A, n =
21), and those on whom percutaneous transhepatic
biliary drainage was performed with the double-wall
puncture technique were admitted during the follow-
ing 5 months (group B, n = 18).
In group A, we used specially designed devices.
A 20- or 21-gauge Chiba needle 15-cm long (M.I.
Tech, Seoul, Korea) was connected to a Y-adaptor
(Boston Scientific, Tullamore, Ireland). A syringe
filled with diluted contrast medium was attached to

AJR:181, September 2003 717


the side arm of the Y-adaptor. A 0.018-inch, 60-cm
guidewire was inserted into the opened central lu-
men of the Chiba needle for immediate access when
the needle punctured the bile duct (Fig. 1). The skin
of the right flank was prepared and 2% lidocaine
was injected with a 22-gauge needle. Single-wall
Downloaded from www.ajronline.org by 163.27.215.117 on 11/03/15 from IP address 163.27.215.117. Copyright ARRS. For personal use only; all rights reserved
puncture began with the advancement of the needle
through the skin to the liver. Subsequently, diluted
contrast medium was injected through the side arm
of the Y-adaptor while the needle was slowly being
advanced into the liver parenchyma under fluoro-
scopic guidance (Fig. 2). After a duct was entered, a
cholangiogram was obtained with further injection
of contrast medium. After injection, the guidewire
was inserted toward the liver hilum and into the
common bile duct. Radiographs were obtained with
the patient in a supine position to measure the depth
of the needle tract. The needle was then removed,
and the thin-walled sheath was inserted over the
guidewire. The wire was replaced by a 0.035-inch
Radifocus guidewire (Terumo Medical, Tokyo, Ja-
pan). Finally, along the guidewire, a biliary drainage
catheter was placed with its tip in the biliary tree or
duodenal loop. If a bile duct was not entered or if pe-
ripheral vessels were punctured during the first trial,
the needle was withdrawn to the liver periphery and
redirected, and the trial was repeated. If the punc-
tured duct was occluded and the guidewire could not
proceed further, we punctured another duct.
In group B, we used the conventional double-
wall puncture technique. The needle was advanced
to 1–2 cm from the vertebral column or 2–3 cm in-
ferior to the dome of the liver. The stylet was re-
moved, and a connecting tube was attached to the
hub for contrast medium injection. Contrast me-
dium was injected continuously while the needle
was slowly withdrawn. After a duct was entered,
radiographs were obtained and the same sequen-
tial steps were repeated.
In both groups, the mean RBC was measured
from the bile specimens sampled on postproce-
dural day 1 and then on postprocedural day 3 or 4.
The number of punctures needed to reach the bile
Fig. 1.—Photograph shows puncture set for single-wall puncture technique. Sixty-centimeter, 0.018-inch
guidewire is introduced into puncture needle with its tip positioned in needle tip (arrow).
718
Lee et al.
duct and the depth of needle tracts from the skin to
the punctured duct in the two groups were mea-
sured and compared. Complications were also re-
corded for both groups. The chi-square test was
used for analysis of the data. A p value of less than
0.05 was defined as statistically significant.
Results
All procedures were technically successful
in both groups. The mean RBC of the bile
specimen in group A was 4.2 × 106/µL and
10.2 × 106/µL in group B (p < 0.05). In most
patients, this hemobilia subsided within 2–3
days in both groups. The mean depth of the
needle tract in group A was 6.02 cm (range,
2.3–8.5 cm) and was 7.72 cm (range, 6.0–9.5
cm) in group B (p < 0.05). The mean number
of punctures was 1.7 (range, 1–3) in group A
and 2.6 (range, 1–7) in group B, but the differ-
ence was not significant. One patient in group
B developed gross hemobilia 3 days after the
procedure as a result of traction of the percuta-
neous transhepatic biliary drainage catheter;
this was alleviated by catheter manipulation.
Transient fever (37.5–38°C) was noted in one
patient in group A and in two patients in group
B. No other significant bleeding or other com-
plications were observed in either group.
Discussion
In most institutions, percutaneous transhe-
patic biliary drainage is considered as an alter-
native when the patient is not a surgical
candidate for the treatment of benign or malig-
nant biliary obstruction. The double-wall punc-
ture technique [3] has relatively low morbidity
and mortality rates in patients with obstructive
jaundice. However, occasionally disastrous
hemorrhagic complications may develop after
percutaneous transhepatic biliary drainage in
patients with impaired coagulation and mini-
mally dilated peripheral bile ducts. Patients
with cholangitis, in particular, may also carry
the risk of septicemia when infected bile flows
into vessels [4].
In general, percutaneous drainage proce-
dures are performed via the shortest distance
from the skin to the target area to avoid vital
organs and vascular structures, but with the
conventional double-wall puncture technique,
multiple blood vessels and other small bile
ducts might be penetrated as the needle pro-
ceeds forward from the skin to the punctured
duct. This can lead to hemorrhagic complica-
tions such as intrahepatic hematoma, traumatic
pseudoaneurysm, or hemobilia. Cases of bile
leakage and peritonitis have also been reported
[2, 5–7] when the conventional double-wall
puncture method was used. In a preliminary
study, we frequently observed the needle pass-
ing through either portal or hepatic veins, even
when the bile duct was successfully punctured
using the double-wall puncture technique.
Liver puncture can now be performed with
relative safety and accuracy using sonographic
guidance [5, 8]. However, small intrahepatic
vessels occasionally cannot be visualized, and
vascular injuries may occur, leading to hemor-
rhagic complications [9]. Goodwin et al. [10]
described a simple method that used a 22-gauge
needle before placement of a percutaneous
transhepatic biliary drainage catheter, which
could be implemented to access a peripheral
duct. In Goodwin’s method, a 0.018-inch wire
is advanced into the central biliary tree after
ductal puncture. The triaxial catheter set is then
passed over the wire, and the inner stylet and
catheter are removed. A hemostatic valve is at-
tached to the outer sheath over the indwelling
guidewire. The guidewire is held in place, the
outer sheath is withdrawn slowly, and diluted
contrast material is injected under fluoroscopic
observation. However, Goodwin’s study uses
the conventional double-wall method, and thus
it still does not resolve the problems associated
with vascular injury.
With our single-wall puncture technique,
ductal puncture begins at the liver capsule
and slowly advances toward the hepatic pa-
renchyma until the needle meets the bile
ducts. Inadvertent vascular injury can thus be
avoided and the risk of hemorrhagic compli-
cation reduced. Our study indicates that the
single-wall puncture technique is safer and
more efficacious than the double-wall punc-
ture method.
AJR:181, September 2003
 Puncture Technique for Biliary Drainage

In conclusion, the single-wall puncture

method is useful in percutaneous transhepatic
biliary drainage and may be safer than the con-
ventional double-wall puncture method, reduc-
ing the risk of postprocedural hemorrhage.
Downloaded from www.ajronline.org by 163.27.215.117 on 11/03/15 from IP address 163.27.215.117. Copyright ARRS. For personal use only; all rights reserved

References
1. Molnar W, Stockum AE. Relief of obstructive jaun-
dice through percutaneous transhepatic catheter: a
new therapeutic method. AJR 1974;122:356–367
2. Ferrucci JT Jr, Mueller PR, Harbin WP. Percutaneous
transhepatic drainage. Radiology 1980;135:1–13
3. Kadir S. The biliary system. In: Kadir S, ed. Di-
agnostic angiography. Philadelphia: Saunders,
1986:645–648
4. Lameris JS, Obertop H, Jeekel J. Biliary drainage
by ultrasound-guided puncture of the left hepatic
duct. Clin Radiol 1985;36:269–274
5. Yee ACN, Ho C-S. Complications of percutane-
ous biliary drainage: benign vs malignant dis-
A B eases. AJR 1987;148:1207–1209
6. Hamlin JA, Friedman M, Stein HG, Bray JF. Percuta-
Fig. 2.—Single-wall puncture in 57-year-old man with carcinoma of pancreas head.
neous biliary drainage: complications in 118 consecu-
A, Cholangiogram was obtained using single-wall puncture technique. Note ductal puncture (arrow) made at pe-
riphery of right hepatic duct, 3 cm from liver capsule. tive catheterizations. Radiology 1986;158:199–202
B, Cholangiogram obtained after further injection of contrast medium shows numerous dilated bile ducts that 7. Mueller PR, vanSonnenberg E, Ferruci JT Jr. Per-
might have been damaged by conventional double-wall puncture technique. cutaneous biliary drainage: technical and cathe-
ter-related problems in 200 procedures. AJR
1982;138:17–23
In our single-wall puncture technique, we RBC in postprocedural bile specimens. Perhaps 8. Makuuchi M, Bandi Y, Ito T, et al. Ultrasonically
guided percutaneous transhepatic biliary drain-
experienced some difficulty in injecting con- the significant difference in RBC between the
age: a single-step procedure without cholangiog-
trast medium through a needle into which a two methods was related to the improved safety raphy. Radiology 1980;136:165–169
0.018-inch wire was inserted. Although this advantage of the single-wall puncture tech- 9. Andersson T, Eriksson B, Lindgren G, Wilander
sometimes required a high injection pressure, nique. Because the single-wall puncture tech- E, Oberg K. Percutaneous ultrasonography-
no complications such as subcapsular bleeding nique avoids undesirable vascular punctures, it guided cutting biopsy from liver metastases of en-
developed. There were no cases in which con- can be considered safer than the double-wall al- docrine gastrointestinal tumors. Ann Surg 1987;
tinuous injection of contrast medium obscured ternative. Furthermore, the fact that the single- 206:728–732
10. Goodwin SC, Bansal V, Greaser LE III, Stainken
the fluoroscopic field and prevented us from wall puncture can reduce the number of vessels
BF, McNamara TO, Yoon HC. Prevention of he-
completing the procedure. transgressed, providing a greater margin of mobilia during percutaneous biliary drainage:
No significant complications appeared in ei- safety, may be explained by the significantly long term follow-up. J Vasc Interv Radiol 1997;8:
ther group, in spite of a significant difference in shorter length of needle pass in our sample. 881–883

AJR:181, September 2003 719