EUS-guided blood patch delivery during liver biopsy: nature’s gel foam

Video Video 1 Case 1 EUS liver biopsy with FNA needle complicated by persistent blood flow within biopsy tract, which is successfully treated with blood patch technique. Case 2 EUS liver biopsy with FNA needle complicated by persistent blood flow within biopsy tract, which is successfully treated with blood patch technique.


INTRODUCTION
EUS-guided liver biopsy is emerging as an alternative form of tissue acquisition to percutaneous or interventional radiology-guided liver biopsy. Recent studies have shown adequate specimen acquisition and an enhanced safety profile. EUS-guided liver biopsy has been found to be extremely safe. The most common adverse events are mainly due to bleeding events. Unfortunately, there are limited endoscopic interventions available to prevent bleeding during liver biopsy.
Autologous blood patches have been used for hemostasis since the 1960s for management of cerebrospinal fluid leaks during lumbar puncture. 1 Recent studies have also shown efficacy with blood patch pleurodesis for alveolaopleural fistula closure. 2 With this in mind, we have developed a novel approach to facilitating hemostasis to prevent active bleeding during EUSguided liver biopsy by delivering a blood patch through the FNB needle into the biopsy tract before needle extraction. This results in cessation of bleeding within the needle tract, thereby preventing post-liver biopsy hemorrhage.

PROCEDURE TECHNIQUE
EUS-guided liver biopsy is performed with a 19-gauge FNB needle. With this particular needle, we perform 1 pass and 3 actuations (see Fig. 1). Before removing the needle from the liver, eFlow color Doppler is used to identify potential bleeding within the liver biopsy tract. If eFlow persists after waiting 2 to 3 minutes, the blood patch technique is performed. While the needle is within the biopsy tract, the FNA stylet is inserted into the needle, pushing out about 25% of the distal needle contents. This "blood patch" acts as a mechanical barrier to facilitate hemostasis.

CASE SUMMARY
In both cases, we encountered active flow within our liver biopsy needle tract after liver biopsy. After waiting 2 to 3 minutes, we saw persistent flow within the biopsy tract, raising concerns for post-liver biopsy hemorrhage. We then performed the blood patch technique by pushing the distal 25% of the needle contents into the needle tract. We show that this maneuver halted flow toward our needle, thereby avoiding postÀliver biopsy hemorrhage and allowing us to safely remove the needle from the liver. Both patients did well after this procedure, and no adverse events were encountered.

CONCLUSIONS
PostÀliver biopsy bleeding is a known adverse event after liver biopsy. Currently, there are no endoscopic interventions available to prevent postÀliver biopsy bleeding. We describe a technique in which a blood patch is delivered into the biopsy tract to facilitate hemostasis and prevent postÀliver biopsy hemorrhage (Video 1, available online at www.giejournal.org).

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