given the segmental anatomy of liver , use of ultrasound in this region has 3 limitations : 1 ) several segments are adjacent to the same hepatic vein ; 2 ) right hepatic vein and its branches are not always visible in the caudal region of the right lobe ; and 3 ) hepatic veins have abundant anatomic variations ( 1 ) . some structures such as glisson s capsule can not be seen via ultrasound . however , when liver is surrounded by ascites and ultrasound beam is perpendicular to the surface of the liver , a linear echo can be seen throughout the liver . moreover , in the absence of ascites on scan , a similar linear echo is seen along the liver , using a 5 to 7.5 mhz linear probe . also , the falciform ligament can not be seen on the ct scan unless it is surrounded by ascites or lipid tissues or fibers are not present in the ligament ; in these cases , this ligament is visible as a linear structure or a linear hyperechoic band within the left intersegmental fissure ; some other ligaments of the liver can be only seen when the liver is surrounded by ascites ( hepatoduodenal , hepatogastric , coronary , and right / and left triangular ligaments ) ( 2 ) . accurate measurement of liver size , due to the limited available field of vision in ultrasound , is difficult , especially when the liver is enlarged . the most widely used method of liver length measurement is the sagittal approach in the mid - clavicular line , which is usually in correspondence with the mid - hepatic line . if the length of the liver in the midclavicular line is more than 15 cm , hepatomegaly should be considered ( 3 ) . generally , liver imaging is performed in order to meet four objectives : 1 ) evaluation of the causes of hepatomegaly or liver - localized tumors ; 2 ) detecting tumors ( primary or metastatic tumors ) ; 3 ) confirming or rejecting inflammatory or parasitic diseases of the liver ; and 4 ) planning for medical , radiological , or surgical treatments ( 4 ) . liver biopsy is the most specific test to assess the nature and severity of liver disease ( 5 ) , and can be helpful in treatment management and planning . there are several ways to obtain a liver biopsy , among which biopsy through the skin is the most common . however , some contraindications such as coagulation disorders have been reported in this method . in these cases , transjugular liver biopsy ( tjlb ) the advantage of this method is that it is not necessary to pierce into the liver capsule . moreover , in case of bleeding during biopsy , blood enters the patient s venous system and his / her hemodynamics will not be affected . in addition , in this procedure , after finding suitable pathways , we can use other diagnostic procedures such as the measurement of hepatic venous pressure gradient ( 7 ) ; we can also follow other remedial measures such as placing a shunt between the portal and hepatic veins ( or other necessary measures ) ( 8) . the specific objective of this study was to determine the safety , effectiveness , complications , and pathological impact of tjlb . this cross - sectional study population consisted of patients with indications for tjlb , who were referred to the radiology department of imam reza hospital , mashhad , iran , 20142015 . considering the patients contraindications to routine skin biopsy and the necessity of liver biopsy for disease management and treatment , the exclusion criteria were as follows : 1 ) lack of platelet dysfunction ; 2 ) prothrombin duration more than 22 seconds ; 3 ) scar on the neck , especially on the jugular vein ; 4 ) lack of contraindications to percutaneous biopsy ; and 5 ) unfeasibility of performing tjlb . in this study , data were collected via questionnaires and observation . siemens - elema radiological device ( 1980 , hamburg , germany ) was utilized , which was equipped with two separate tubes with simultaneous exposure of facio - lateral regions . therefore , fluoroscopic and angiographic imaging were simultaneously performed without transferring the patient from one bed to another . also , a doppler ultrasound machine ( sonosite m - turbo , sonosite , bothell , wa ) was used in this study . before the biopsy , patients with indications for tjlb were admitted to the gastrointestinal division of internal medicine department of imam reza hospital . after preliminary analysis by a subspecialist of gastroenterology , the patients were referred to the radiology department . after six hours of fasting , patients were transferred to the angiography room at the radiology department , and were continuously monitored by nurses in terms of vital signs and heart function . a pillow was placed under the patient s neck to allow sufficient neck extension ; therefore , the radiologist had access to the jugular vein . afterwards , the location of the internal jugular vein on the right side of the neck was identified . by using 2 cc syringes , 1 cc of lidocaine 2% was cautiously injected for local anesthesia around the jugular vein ( injection should not enter the blood , since it may lead to arrhythmia ) ( figure 1 ) . a guide wire was inserted , which crossed the path of superior vena cava , right atrium , and inferior vena cava . all the mentioned procedures were controlled via fluoroscopy by the radiologist to prevent the subintimal placement of the catheter , given the associated risks for the patient . after putting the catheter in the correct position , a specific biopsy needle was inserted by a radiologist . by maintaining an appropriate distance from the liver capsules , radiologist distanced himself from the needle and liver capsule , since in cases of capsule rupture , a major complication might occur and the patient might experience severe peritoneal bleeding ; presumably , the patient might die since the bleeding is usually uncontrollable ( figure 2 ) . tissue samples were obtained from patients and reviewed by radiologists ( macroscopic review ) . the sample size and quantity , as well as the initial quality ( in terms of damage ) , were checked , and if the sample size was not adequate or the sample was fragmented , another biopsy was performed around the site of the previous biopsy , following the same procedure . in this study , after each sampling , the sample was maintained in saline and immediately given to a pathologist . then , the harvested area was controlled via fluoroscopy and contrast injection and possible complications were reviewed . after sampling , the perforated skin regions were compressed for one minute to prevent bleeding and hematoma in the neck , which might put pressure on the airway . abdominal ultrasound was performed to check the presence of free fluid or hematoma in the liver and peritoneal cavity . the obtained results were recorded , and nurses monitored and recorded the vital signs for 24 hours . moreover , other symptoms such as abdominal pain , nausea , vomiting , and shortness of breath , chest pain , and neck pain were evaluated and recorded . twenty - four hours after the biopsy , patients were visited by a gastroenterologist and abdominal sonography was performed again for evaluating the probability of any complications . finally , the histological report was prepared by the pathologist , which included the sample size , rate of sample injury , and the count of complete portal tract ( cpt ) ; then , the final diagnosis was made . the collected data from the questionnaires and pathological reports were entered into spss version 16 ( spss inc . , chi - square test was applied for measuring the statistical difference between the groups . in all the tests , this cross - sectional study population consisted of patients with indications for tjlb , who were referred to the radiology department of imam reza hospital , mashhad , iran , 20142015 . considering the patients contraindications to routine skin biopsy and the necessity of liver biopsy for disease management and treatment , the exclusion criteria were as follows : 1 ) lack of platelet dysfunction ; 2 ) prothrombin duration more than 22 seconds ; 3 ) scar on the neck , especially on the jugular vein ; 4 ) lack of contraindications to percutaneous biopsy ; and 5 ) unfeasibility of performing tjlb . siemens - elema radiological device ( 1980 , hamburg , germany ) was utilized , which was equipped with two separate tubes with simultaneous exposure of facio - lateral regions . therefore , fluoroscopic and angiographic imaging were simultaneously performed without transferring the patient from one bed to another . also , a doppler ultrasound machine ( sonosite m - turbo , sonosite , bothell , wa ) was used in this study . before the biopsy , patients with indications for tjlb were admitted to the gastrointestinal division of internal medicine department of imam reza hospital . after preliminary analysis by a subspecialist of gastroenterology , the patients were referred to the radiology department . after six hours of fasting , patients were transferred to the angiography room at the radiology department , and were continuously monitored by nurses in terms of vital signs and heart function . a pillow was placed under the patient s neck to allow sufficient neck extension ; therefore , the radiologist had access to the jugular vein . afterwards , the location of the internal jugular vein on the right side of the neck was identified . by using 2 cc syringes , 1 cc of lidocaine 2% was cautiously injected for local anesthesia around the jugular vein ( injection should not enter the blood , since it may lead to arrhythmia ) ( figure 1 ) . a guide wire was inserted , which crossed the path of superior vena cava , right atrium , and inferior vena cava . all the mentioned procedures were controlled via fluoroscopy by the radiologist to prevent the subintimal placement of the catheter , given the associated risks for the patient . after putting the catheter in the correct position , a specific biopsy needle was inserted by a radiologist . by maintaining an appropriate distance from the liver capsules , radiologist distanced himself from the needle and liver capsule , since in cases of capsule rupture , a major complication might occur and the patient might experience severe peritoneal bleeding ; presumably , the patient might die since the bleeding is usually uncontrollable ( figure 2 ) . tissue samples were obtained from patients and reviewed by radiologists ( macroscopic review ) . the sample size and quantity , as well as the initial quality ( in terms of damage ) , were checked , and if the sample size was not adequate or the sample was fragmented , another biopsy was performed around the site of the previous biopsy , following the same procedure . in this study , after each sampling , the sample was maintained in saline and immediately given to a pathologist . then , the harvested area was controlled via fluoroscopy and contrast injection and possible complications were reviewed . after sampling , the perforated skin regions were compressed for one minute to prevent bleeding and hematoma in the neck , which might put pressure on the airway . abdominal ultrasound was performed to check the presence of free fluid or hematoma in the liver and peritoneal cavity . the obtained results were recorded , and nurses monitored and recorded the vital signs for 24 hours . moreover , other symptoms such as abdominal pain , nausea , vomiting , and shortness of breath , chest pain , and neck pain were evaluated and recorded . twenty - four hours after the biopsy , patients were visited by a gastroenterologist and abdominal sonography was performed again for evaluating the probability of any complications . finally , the histological report was prepared by the pathologist , which included the sample size , rate of sample injury , and the count of complete portal tract ( cpt ) ; then , the final diagnosis was made . the collected data from the questionnaires and pathological reports were entered into spss version 16 ( spss inc . , chi - square test was applied for measuring the statistical difference between the groups . in all the tests , p - value in this study , 24 patients ( 13 males and 11 females ) were included . the mean age of the patients was 25.35 years , with a standard deviation of 9.78 . the subjects were within the age range of 1957 ( 70.8% ) years and 7 ( 29.2% ) patients were younger than 29 years . in the present study , 95.8% of the patients underwent this diagnostic method due to platelet coagulation disorders and platelet count < 30,000 . only in 1 patient ( 4.2% ) , this procedure was performed due to hemophilia . in our study , the biopsy was successful in 21 patients ( 87% ) . however , due to sustained cardiac arrhythmia ( in two patients ) and unfeasibility of catheterization of the right hepatic vein ( in one patient ) , the procedure was unsuccessful in 3 patients ( 13% ) . figure 2 shows the duration of intervention ( in minutes ) . according to this diagram , in 5 patients , the intervention duration lasted 30 minutes . the mean and standard deviation of the intervention duration were 23.80 and 9.34 , respectively . table 1 indicates the frequency distribution of complications in the studied patients . in this study , there were no major complications in 91.7% of the patients ; however , minor complications were reported in 62.5% of the subjects . three patients ( 12.5% ) had neck pain at the time of puncture , eight patients ( 33.3% ) had transient pain in the liver area while doing the biopsy and one subject ( 2.4% ) had abdominal pain after the biopsy ; also in one patient , there was contrast media extravasations under the liver capsule . two patients ( 8.3% ) had sustained cardiac arrhythmia , which was the only major complication among patients . after the intervention , abdominal ultrasound was performed for all patients , who showed no clinical indications . also , all the patients were under consistent care for 24 hours after the intervention in order to prevent any complications . in most patients with successful sampling , two biopsy specimens were taken ( 11patients ) ; also , in 8 and 2 patients , 1 and 3 biopsies were performed , respectively . the biopsies were suitable for pathological reports in 20 patients ; in one patient , the biopsy was not suitable for the pathological report . three patients were excluded from the study due to sustained cardiac arrhythmia ( in two patients ) and unfeasibility of catheterization of the right hepatic vein ( in one patient ) . figure 3 shows the frequency of cpt count in the biopsies . according to this diagram , the maximum cpt count in the biopsies was 6 ( with a frequency of 4 ) , followed by 5 and 7 ( each with a frequency of 3 ) . the mean  standard deviation of cpt count was 6.75 2.95 . according to liver biopsies , mild inflammation ( 8 patients ) and cirrhosis of the liver ( 8 patients , maximum frequency ) were diagnosed ; autoimmune hepatitis was the next most prevalent diagnosis , reported in 4 cases . it should be noted that in pathological reports , more than one diagnosis was mentioned for some patients . transient pain in the liver area during biopsy was seen in seven men and one woman . however , the relationship between the two variables was not statistically significant ( p=0.090 ) . the duration of intervention ranged between 1040 minutes while most of the procedures lasted for 40 minutes ( 88% ) , but despite the differences between the two genders in duration , no significant statistical relationship was observed between these variables ( p=0.126 ) the most common complication was transient pain in the liver during biopsy , which had the highest incidence in the age groups of 3033 years and > 44 years . however , no significant statistical association was observed between these two variables ( p=0.243 ) . in this study , sampling was successful in most patients ( 87% ) without causing any major complications ; only 3 patients ( 13% ) experienced biopsy - related complications . the intervention duration was relatively short and in most patients , biopsies were helpful for diagnosis with proper cpt count . given that simple random sampling was employed in this study , 54% of the subjects were males and 46% were females ; gender distribution was similar to that of cholongitas study ( 55% male and 44% female ) , which assessed the performance of tjlb in patients without liver transplantation ( 7 ) . contrarily , in nassiri s study , all patients were females ( 9 ) . in dawson s study , this method was performed for only 6 patients , among whom only one was female ( 10 ) . in the current study , patients who met the inclusion criteria were within the age range of 1957 years , with a mean of 35.25  9.78 years . the mean age of the participants in various similar studies is different . in a study by gorriz and colleagues with a sample size of 77 patients , participants were within the age range of 1569 years with a mean of 45 years ( 11 ) . in the study by nassiri et al . , the sample size included 12 patients , aged 1454 years , with a mean age of 29.8 years ( 9 ) . in the cholongitas study , which included 165 patients , the mean of subjects age was 4815 years ( 7 ) . the comparison between these studies indicates that the age distribution varies , depending on the inclusion criteria . based on tjlb findings in our study , one case was diagnosed with hemophilia and 23 patients presented with bleeding disorders and platelet count < 30,000 . meanwhile in the study by nassiri et al . , all the patients had hemophilia ( 9 ) . also , in dawson s study , conducted in a hemophilia treatment center , all the patients were diagnosed with congenital bleeding disorders ( von willebrand s disease and hemophilia ) and hepatitis c ( and one case of hiv ) ( 10 ) . in addition , in lee s study , in a sample size of 21 patients , all subjects had chronic hepatitis and cirrhosis , and 19 patients suffered from liver failure after bone marrow transplantation ; in two other patients , the initial diagnosis was uncertain ( 12 ) . in our study , performed on 24 patients , the sampling was successful in 87.5% of the cases , and adequate liver biopsy specimens were obtained via tjlb . beckmann s study , conducted on 102 patients in 2009 , indicated a technical success rate of 82% ( 13 ) . the success rate of a diagnostic intervention depends on several factors including the equipment , researcher s skills , indications , and inclusion criteria . considering the reported results in other studies , the intervention duration in our study was 23.809.34 min , ranging from 10 to 40 minutes . however , in gorriz s study , the average intervention duration was 48 min ( 11 ) ; also , in miraglia s study , considering the extra time needed for frozen section , the average duration was 80 min ( 14 ) . in our study , the incidence rate of complications varies in different studies ; only miraglia s study , conducted on 17 patients , reported no adverse side - effects ( 14 ) . also , in dawson s study , conducted on six patients , only one patient had complaints of pain in the right upper quadrant of the liver ( 10 ) therefore , it can be concluded that occurrence of major complications is uncommon in this diagnostic method and most of the minor complications are self - limited and not threatening for the patient . given that in the current study , neck puncture was performed under ultrasound guidance , no damage to the carotid or endothelium of internal jugular vein or neck hematoma was observed in our patients . ultrasound - guided tjlb can be an effective method if performed by an experienced radiologist . these biopsies , considering the small error percentage detected by pathologists , can be useful for patients who are contraindicated to other types of biopsy . given that this study was performed on 24 patients , further research with greater sample size is recommended to accurately determine high - risk patients and other probable indications .
introductiontransjugular liver biopsy ( tjlb ) is a diagnostic radiological intervention , applied to patients with contraindications to percutaneous or laparoscopic liver biopsy . 
 the aim of this study was to determine the safety , effectiveness , complications , and pathological impact of tjlb.methodsthis cross - sectional study was conducted on 24 consecutive patients , undergoing tjlb at imam reza hospital , affiliated to mashhad university of medical sciences , from april 2010 to march 2011 . 
 the inclusion criteria were coagulopathy , thrombocytopenia , and ascites . 
 tjlb was performed by a radiologist , and a guide wire was inserted in the right jugular vein . 
 right atrium and middle hepatic vein were catheterized , and then , cook quick - core biopsy needle was used by ultrasound guidance . data 
 analysis was performed by spss version 16.resultsthe sample size included 24 subjects ( 54% males and 46% females ) . 
 success rate of tjlb was reported as 87.5% and the intervention duration was 23.899.34 min . 
 no complications were reported in 37.5% of the patients ; however , pain in the right upper quadrant ( 33.3% ) , leakage of contrast substance into the liver capsule ( 4.2% ) , and diffuse abdominal pain ( 4.2% ) . in 83% of biopsies , suitable samples were obtained for histopathological diagnosis , and 13% of patients were excluded from the study . according to the results , the mean central port track ( cpt ) was 6.75 
 2.95.conclusiontjlb is a relatively effective and safe procedure for patients with contraindications to percutaneous liver biopsy .