Percutaneous Intraductal Ultrasonography Guided Biliary Reconstruction: Single-Stage Management of Indeterminate Biliary Obstruction and Intrastent Stenosis

Abstract

Percutaneous transhepatic cholangiography is a useful imaging technique during biliary evaluation and interventions. However, contrast cholangiography alone provides limited information on the nature, quality, or severity of potentially treatable biliary conditions. In this case report, transhepatic intravascular ultrasound is utilized to perform intraductal ultrasonography during complex biliary reconstruction for the evaluation of indeterminate biliary obstruction and management of intrastent stenosis.

Keywords

intravascular ultrasound - intraductal ultrasound - biliary reconstruction

Introduction

Despite extensive workup, including laboratory tests, cross-sectional imaging, and endoscopic retrograde cholangiopancreatography (ERCP), up to 20% of biliary strictures remain indeterminate. Computed tomography (CT) and magnetic resonance (MR) imaging are invaluable in the detection of associated malignant tumors and lymphadenopathy. However, in the absence of definitive evidence of malignancy, cross-sectional imaging is limited in determining the etiology of the stricture. Dedicated CT and MR protocols can achieve very high sensitivities (approaching 88%) for malignant strictures but with low specificities (<50%).[1] [2] [3] Furthermore, in patients with prior biliary reconstruction and intrastent stenosis (ISS), existing modalities are limited with respect to evaluating the etiology and severity of the underlying obstruction.

Endoscopic intraductal ultrasonography (IDUS) is a sensitive (88–93%) and specific (90%) technique for evaluating malignant strictures.[4] [5] Tumor staging can be performed simultaneously and more accurately than endoscopic ultrasound (EUS). In a comparative series by Menzel et al, IDUS more accurately determined T stage (78 vs. 54%) with equivalent performance in N stage (60 vs. 62.5%).[6] Meister et al defined the technical limits of high-resolution IDUS staging at T3 and N1, due to the much higher frequency (IDUS >12 MHz vs. EUS 7.5 MHz) and consequent reduction in tissue penetration depth[4] [7] [8] to approximately 2 cm. Hence, despite advantages, endoscopic IDUS remains technically challenging and is not widely available.

Intravascular ultrasound (IVUS) has been used to evaluate blood vessels as a diagnostic imaging tool and to provide decision support during vascular interventions. In this case report, percutaneous transhepatic IDUS is performed using intraprocedural IVUS during biliary interventions to evaluate potential causes of indeterminate biliary obstruction and to assist with planning during complex biliary reconstruction. Potential benefits of IDUS during biliary reconstruction include tumor staging, identification of the nature and degree of biliary obstruction, optimization of stent sizing, and enhancement of procedural result(s).

Case Studies

Ethics and Institutional Review Board approval are not required for this study.

Case 1 (Intrastent Stenosis with Recurrent Biliary Obstruction)

A patient with a history of tumor-related common bile duct (CBD) obstruction and CBD stenting presented with new left biliary obstruction and hyperbilirubinemia. The patient was referred for left percutaneous biliary decompression. Under general anesthesia, the left peripheral bile duct was accessed using a triaxial introducer system (Accustick, Boston Scientific, Marlborough, MA, United States) and a 10 cm × 10 Fr introducer sheath was placed (Terumo Pinnacle, Somerset, NJ, United States). Following contrast cholangiography, a normal saline drip bag was connected to the introducer sheath and opened to gravity to distend the proximal bile ducts. An over-the-wire (OTW) IVUS catheter (VISIONS PV, Philips, Cambridge, MA, United States) was advanced across the left biliary occlusion and into the small bowel. Percutaneous transhepatic IDUS was performed in order to evaluate the extent of new left main obstruction for precise stent placement, as well as severity of ISS within the CBD stent by advancing or retracting the IVUS catheter OTW across each biliary region of interest ([Fig. 1A]). Initial IDUS demonstrated complete ISS of the CBD stent with chronic debris/tissue ingrowth ([Fig. 1B]) and obstruction of the central left main bile duct ([Fig. 1C]). Owing to refractory ISS despite cholangioplasty and attempted Fogarty removal of the intrastent occlusion, the decision was made to proceed with biliary reconstruction. Stent size was selected based upon a 10% oversize of the IDUS-measured patent segment of the left bile duct proximal to the obstruction. Following placement of a continuous 8-mm metallic stent (Zilver, Cook Medical, Bloomington, IN, United States) across the existing stenotic CBD stent and through the occluded central left main bile duct, there was improved patency of the “stent-in-stent” segment of the CBD ([Fig. 1D]) and left main bile duct ([Fig. 1E]) with rapid biliary to bowel transit of contrast and bile into the small bowel ([Fig. 1F]). An internal–external biliary drain was placed, and the patient subsequently underwent staged removal of the biliary drain with normalization of the total bilirubin and subsequent ability to resume systemic chemotherapy.

Fig. 1 (A) Left transhepatic cholangiogram with intrastent stenosis (ISS) of existing common bile duct (CBD) stent and left main bile duct obstruction (intravascular ultrasound [IVUS] catheter in place). Transhepatic intraductal ultrasonography (IDUS) of the (B) CBD stent and (C) central left main bile duct demonstrating severe ISS (yellow arrow) and left main stenosis with dilated side branch (red arrow). Improved patency on repeat IDUS following biliary reconstruction within the (D) CBD “stent in stent” (blue arrows) and (E) left main bile duct, respectively. (F) Final cholangiogram with rapid bile transit across the reconstructed bile duct segments.

Case 2 (Cholangiocarcinoma with Indeterminant Stricture)

A patient with cholangiocarcinoma and left-sided intrahepatic biliary dilatation ([Fig. 2A]) was brought into the interventional radiology (IR) suite for evaluation and biliary decompression under general anesthesia. A left peripheral bile duct was accessed under US guidance followed by placement of a 10-Fr side arm sheath. A diagnostic cholangiogram was performed. A saline drip was administered via the side arm sheath to distend the proximal biliary duct(s). An OTW IVUS catheter (VISIONS PV, Philips) was advanced across the biliary occlusion. Percutaneous transhepatic IDUS was then performed across the occluded biliary segment ([Fig. 2B]) demonstrating hypoechoic tumor extending beyond the bile duct wall resulting in compression of the central left main bile duct ([Fig. 2C]) with an intraductal component of tumor also identified ([Fig. 2D]). IDUS measurements were obtained, and a bare metallic stent was then used to reconstruct the obstructed left central to proximal CBD (images not shown). Following biliary reconstruction, the patient's hyperbilirubinemia resolved, and the patient was able to initiate systemic therapy.

Fig. 2 (A) Coronal magnetic resonance imaging (MRI) with left biliary obstruction and central biliary mass. (B) Left transhepatic cholangiogram with central left main bile duct obstruction (intravascular ultrasound [IVUS] catheter in place). Staging transhepatic intraductal ultrasonography (IDUS) was performed demonstrating (C) hypoechoic tumor (yellow asterisk) present within the hepatic parenchyma and (D) intralumenal extension (yellow asterisk) within the left central main bile duct.

Discussion

Managing indeterminate biliary strictures and recurrent biliary obstruction due to complex ISSs following biliary reconstruction can be challenging. Current imaging modalities utilized during percutaneous biliary evaluation and intervention include contrast cholangiography and direct optical visualization. Cholangiography is widely available but is limited as it relies on indirect visualization of the anatomy and intralumenal processes. Optical imaging, such as Spyglass, enables direct intralumenal visualization of the bile ducts, but is limited to surface imaging and not available in many interventional procedure suites due to high costs and/or requirements for specialized training and hospital credentialing.

In 2017, Chick et al described the use of an IVUS catheter to guide transbiliary biopsy of an inaccessible pancreatic tumor, demonstrating the therapeutic value of IVUS during biliary interventions.[9] In the current case report, transhepatic IVUS was utilized to perform IDUS during evaluation, staging, and stent planning of an indeterminate biliary stricture (Case 2) and facilitate/provide decision support during complex biliary reconstruction in a patient with concomitant ISS of a preexisting CBD stent and new, extensive left main and proximal native CBD biliary obstruction (Case 1).

Percutaneous transhepatic IDUS provides unique advantages. IVUS catheters are available in many interventional programs and are relatively less expensive than digital optical catheters and cholangioscopes. Owing to the ability to appose and image the biliary wall and beyond, IDUS can be used to stage tumors, as illustrated in Case 2. Furthermore, much like the use of IVUS for intravascular applications, IDUS can provide valuable decision support during biliary reconstruction interventions by accurately identifying the anatomy and structural pathology, provide direct measurements for device selection, and differentiate lesion composition, that is, soft tissue versus debris versus calcified matrix/stones. Transhepatic IDUS does not require any additional specialized equipment or accessories other than the IVUS catheter and imaging platform. Moreover, no specialized training or additional hospital privileges are required.

In conclusion, the use of transhepatic IVUS to perform IDUS during biliary interventions may be a useful complement to existing imaging modalities by providing valuable information during evaluation and interrogation of indeterminate biliary strictures and facilitating decision support during biliary reconstruction procedures.

Conflict of Interest

J.J.P. is a proctor for Sirtex Medical, Inc., and medical advisory board member for Boston Scientific and Varian. J.Q. has no disclosures.

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Publication History

Article published online:
28 March 2025