Transhepatic techniques for accessing the biliary tract

Gaining access to the biliary tract by minimal invasive image-guided techniques is the forefront procedure for interventionalists to manage biliary disease. The technical know how and learned maneuvers are the fundamental skill sets of an interventional radiologist. This article details the technical maneuvers that can be utilized to gain access to the biliary tract with a needle and/or catheter/wire combinations. These techniques include (1) fluoroscopic-guided needle localization from a percutaneous transhepatic approach, (2) different types of wire access/entry into the biliary system, (3) the use of intrabiliary snares as targets for secondary/additional biliary access, (4) recannulating transhepatic biliary tracts after inadvertent discontinuation of percutaneous biliary drains, and (5) ultrasound-guided left-sided biliary duct access.