Percutaneous Transhepatic Cholangiography

Background and indications

Percutaneous transhepatic cholangiography (PTC) is a diagnostic and interventional procedure involving puncture of intrahepatic bile ducts through the hepatic parenchyma, then opacification with contrast injection under fluoroscopy. It provides precise biliary tree mapping and is the first step for percutaneous biliary drainage or biliary intervention (dilation, stent).

It is indicated when endoscopic ERCP is impossible or has failed, for characterization of high biliary obstructions (Klatskin tumor), post-operative bile leaks, and benign biliary strictures on biliodigestive anastomosis.

Pre-procedure assessment

Assessment includes biliary MRI (MR cholangiopancreatography — MRCP) or CT, coagulation panel (PT > 50%, platelets > 50,000), and antibiotic prophylaxis (cholangitis risk).

Procedure

Under local anesthesia and sedation, a fine needle (21-22G) is inserted through hepatic parenchyma under fluoroscopic (and/or ultrasound) guidance. Multiple punctures may be needed to catheterize a bile duct (typically right intercostal approach for right ducts, or epigastric for left ducts). Contrast is injected to opacify the biliary tree. If drainage is planned, a guidewire is advanced and a drain placed. The procedure takes 30-60 minutes.

Results and scientific evidence

PTC technical success rate is 95-99% with dilated bile ducts and 70-85% with non-dilated ducts. PTC provides superior biliary mapping compared to ERCP for complex hilar obstructions. It remains indispensable in surgical planning for hilar tumors and post-surgical biliary strictures inaccessible by endoscopy.

Risks and complications

Cholangitis/biliary sepsis (2-5%), hemorrhage (hemobilia: 2-3%), bile leak (1-3%), pain (20-30%). Procedural mortality is < 1%. Antibiotic prophylaxis significantly reduces cholangitis risk.

Recovery

1-2 night hospitalization (hemorrhagic and infectious monitoring). If a drain is placed, see "Percutaneous biliary drainage" page.

Practical information

The procedure is performed as a short inpatient stay. It is performed by an interventional radiologist, in coordination with the gastroenterologist and hepatic surgeon.