A Technique to Improve the Success of Stent Placement for High-Level Malignant Biliary Obstruction Through PTCD...

For patients with high-level malignant biliary obstruction-confirmed following initial percutaneous transhepatic cholangiography drainage (PTCD) performed for preoperative bilirubin reduction and subsequently determined to be unresectable-biliary stent placement via the existing PTCD tract represents a straightforward, minimally invasive, and clinically feasible therapeutic strategy. However, the procedure may be technically challenging if the catheter tract is tortuous. This case report describes a refined interventional technique to overcome such limitations. A 56-year-old man was admitted due to right upper quadrant abdominal pain and progressive jaundice involving both the skin and sclera. Initial PTCD was performed to achieve rapid biliary decompression and reduce serum bilirubin levels. Subsequently, comprehensive imaging and histopathological evaluation established the diagnosis of unresectable hilar cholangiocarcinoma with intrahepatic and multiple osseous metastases. Given the patient's unresectability and need for durable biliary drainage, stent placement through the preexisting PTCD tract was selected as the optimal palliative intervention. During the procedure, a hydrophilic guidewire was advanced through the indwelling PTCD catheter into the duodenum through the obstructed hepatic portal bile duct and common bile duct; the catheter was then withdrawn over the wire, and a vascular sheath (size similar to the original PTCD tract) was inserted coaxially over the guidewire. This maneuver effectively straightened the access pathway and provided mechanical support for subsequent device delivery. A self-expanding metallic biliary stent was then successfully deployed along the PTCD tract. Postprocedural cholangiography confirmed complete stent apposition, unobstructed bile flow into the duodenum, and absence of procedural complications. This case demonstrates that the judicious use of a vascular sheath during PTCD tract-based stent placement enhances procedural safety, efficiency, and technical success-while minimizing procedural complexity and patient discomfort-and represents a practical, reproducible refinement for biliary stent deployment in anatomically challenging high-grade malignant biliary obstruction.