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Indications / Contraindications
Scheduled Exchange
- Every 3 months for external and internal-external biliary drainage catheters — encrustation, biofilm formation, and sludge accumulation cause routine occlusion
- Earlier if: catheter malfunction (poor drainage, increased pain, fever, jaundice returning)
- Catheter degradation — softening or cracking of hub
- Patient request for smaller or different catheter type
Unscheduled Exchange
- Catheter occlusion (most common) — indicated by: ↑bilirubin, recurrent jaundice, fever, purulent bile, or no drainage from bag
- Partial dislodgement (catheter pulled back but still in tract)
- Side-hole malposition (all drainage into bag = internal holes not past stricture)
- Post-procedure assessment showing inadequate drain position
- New or progressive stricture requiring catheter repositioning
Contraindications
- Complete dislodgement (tract loss) — new PTBD access required, not exchange
- Suspected hemobilia (bloody bag) — evaluate before exchange
- Uncorrectable coagulopathy — relative; SIR Cat 2, low risk with exchange over wire
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Pre-Procedure Checklist
Review recent imaging. Has obstruction changed? New stricture? Progression of malignancy affecting catheter position needs? Consider whether repositioning or upsizing is indicated at this exchange.
Cholangiogram through existing catheter BEFORE exchange. Perform same sitting or prior day. Establishes current catheter position and biliary anatomy before removing the old catheter.
Antibiotics: situational. Give ciprofloxacin or ceftriaxone if fever, known biliary infection, immunocompromised, or diabetic. Not routine for a clean scheduled exchange in an afebrile patient.
Confirm new catheter ordered. Same type and size, or as clinically indicated. Have the replacement catheter at the table before you start.
Local anesthesia only. Mature transhepatic tract tolerates exchange with minimal lidocaine at the skin entry site. No systemic sedation required in most patients.
Positioning. Supine for right hepatic approach. Supine or slight left lateral decubitus for left hepatic approach.
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Relevant Anatomy
The Mature Biliary Tract
- Fibrosed channel from skin → hepatic parenchyma → bile duct. The hepatic parenchyma seals around the catheter, providing natural hemostasis.
- Tract is maintained by catheter presence. Without catheter → tract begins closing within hours. This is the fundamental reason wire control is paramount.
- Transhepatic = hemorrhage risk if wire lost — hepatic artery and portal vein branches run within the parenchyma traversed by the tract.
Tract Timeline
- Immediately after wire loss: Mature tract holds open for approximately 30–60 minutes
- After 1–2 hours: Tract becomes significantly narrowed — recannulation increasingly difficult
- After several hours: Tract effectively closed — new transhepatic puncture required
- Older and more fibrosed tracts (months of catheter) hold longer than recent tracts
Vascular Danger Within Tract
- Hepatic artery branches run parallel and adjacent to bile ducts (portal triad)
- Portal vein tributaries traverse the parenchyma adjacent to the catheter tract
- Injury during wire manipulation can cause hemobilia or pseudoaneurysm
- Mature tracts that are well-established are generally safer than immature tracts (<4 weeks)
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Technique
Default RadCall approach · share your own below
Supplies
Fluoroscopy
Dilute contrast + syringes
0.035" Amplatz stiff wire
New biliary drain (same type/size or as indicated)
1% lidocaine (minimal)
0-silk suture
Drainage bag
Steps
1
Cholangiogram through existing drain
Inject 10–15 mL dilute contrast. Document: catheter position, side-hole location relative to stricture, biliary anatomy, any extravasation or significant change. Assess whether catheter needs repositioning at this exchange.
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Unlock internal suture/string if present
Biliary catheters often have a locking string (Cope loop or locking mechanism). Unlock before wire passage to allow the catheter to straighten for removal.
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Advance Amplatz stiff guidewire
Thread the Amplatz stiff wire through the existing catheter. Advance it well into the biliary system — ideally into the common bile duct or duodenum if this is an internal-external drain. Maximum purchase prevents wire loss during catheter removal.
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Hold wire, remove old catheter
Maintain a firm grip on the wire at the skin level with one hand. With the other, withdraw the old catheter in one smooth motion. Confirm wire still in position immediately by fluoroscopy. Never let go of the wire.
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Advance new catheter over wire
Track the new catheter over the wire to the same depth and position as the old catheter. Use the radiopaque marker as a guide. If repositioning is needed (e.g., all sideholes should straddle the stricture), adjust position now under fluoroscopic guidance.
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Post-exchange cholangiogram
Confirm catheter position: sideholes above AND below stricture for internal-external drain; free flow of contrast into duodenum if crossing stricture; no extravasation. Document the cholangiogram.
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Secure and connect
Suture catheter to skin with 0-silk. Connect drainage bag. Confirm bile drains freely. Document new catheter size, type, and position. Schedule next exchange in 3 months.
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Troubleshooting
Problem
Wire won't pass through occluded catheter
Likely cause: Sludge, biofilm, or inspissated bile completely occluding the catheter lumen.
Next step: Inject contrast first — may dislodge sludge and demonstrate the occlusion level. Try gentle rotation of the wire. If truly occluded: place a new wire alongside the catheter under fluoroscopy through the skin entry site, then exchange both simultaneously. A Chiba needle alongside the catheter through the same tract can also facilitate access.
Problem
Lost wire (most feared complication)
Likely cause: Wire slipped during catheter removal. Premature wire release before catheter fully removed.
Next step: Act immediately. A mature transhepatic tract stays patent for approximately 30–60 minutes. Insert a new wire under fluoroscopic guidance through the tract using a 4Fr angled catheter directed along the known tract trajectory. Dilute contrast can help outline the tract. If tract closes → new PTBD access required.
Problem
New catheter won't track to intended position
Likely cause: Wire has buckled or looped, particularly in a dilated biliary system. Catheter kinking at the tract angulation.
Next step: Confirm wire position under fluoroscopy — may need to advance wire further into duodenum for more purchase. Consider a hydrophilic-coated catheter (tracks more easily through tortuous tracts). A stiffer dilator passed first may help straighten the tract.
Problem
Hemobilia after exchange
Likely cause: Pink or blood-tinged bile immediately after exchange is common and usually clears. Bright red pulsatile output in the bag is concerning for arterial injury or pseudoaneurysm.
Next step: Pink bile — monitor and flush; usually clears within hours. Bright red pulsatile blood: CT angiography → hepatic artery embolization if pseudoaneurysm confirmed. Never remove the drain prematurely in the setting of active hemobilia.
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Complications
Procedure-Related
- Wire/tract loss (most feared) — prevents catheter replacement without new hepatic puncture; act immediately if wire lost
- Cholangitis / bacteremia (~2–5% of exchanges) — antibiotic prophylaxis in at-risk patients; ensure drain is draining after exchange
- Hemobilia — minor is common; significant pulsatile hemobilia needs CT angiography
- Catheter malposition — all side-holes must straddle the stricture; verify on post-exchange cholangiogram
Minor / Manageable
- Bile leak at entry site — often resolves with catheter in good position; skin care important
- Pain at exchange — local anesthesia at skin site is usually sufficient for mature tract; rarely needs sedation
- Vasovagal — monitor during procedure; IV access recommended
- Delayed occlusion — prevent with regular 3-month exchange schedule and daily flushing protocol
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Post-Procedure Care
Immediate Monitoring
- Output monitoring: bile should drain freely from bag within minutes of exchange
- Bile color: yellow-green normal. Bloody = monitor closely. Purulent = active infection requiring antibiotics
- Confirm suture is secure and bag connected before patient leaves fluoroscopy suite
- Vital signs check before patient leaves if any concern
Capping Trial
- If considering internal drainage after exchange: cap 24–48h post-exchange to confirm internal drainage is functioning
- During cap trial: monitor for pain, fever, or jaundice (suggests internal drainage failing)
- If cap trial fails → uncap and return to external drainage; re-evaluate catheter position
Patient Education
- Drain flushing technique: 5–10 mL sterile saline q12h maintains catheter patency
- Dressing care: change every 3–5 days or when soiled; inspect entry site for erythema or bile leak
- When to call IR: no output, fever, increasing pain, bloody bag, catheter appearing to have moved or pulled out
- Next exchange scheduled: 3 months from today. Reinforce this with written instructions.
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Critical Pearls
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NEVER let go of the wire. Exactly as with nephrostomy exchange, wire loss equals a new hepatic puncture. Maintain firm grip at skin level throughout the catheter removal. This is the single most important step.
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Always do a cholangiogram BEFORE removing the old catheter. Do not assume the catheter is still in the correct position. The pre-exchange cholangiogram establishes the map before you remove the catheter and your window closes.
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Amplatz stiff wire is essential. A floppy wire in a biliary system will not maintain adequate tract during catheter exchange. Use the stiffest wire that can be safely advanced to the deepest position possible in the biliary tree.
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Advance wire as far as possible before exchanging. Ideally into the duodenum if the drain crosses the stricture. More wire purchase in a well-supported position means a safer, smoother exchange.
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Regular 3-month exchanges prevent emergency procedures. The vast majority of after-hours biliary calls for occlusion are patients who missed scheduled exchanges. Reinforce the schedule clearly at every visit.
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If wire is lost, act immediately — do not wait for help to arrive. You have a 30–60 minute window. A 4Fr angled catheter directed into the known tract under fluoroscopy and contrast outlining the tract is your fastest recannulation approach. Can also use the inner portion of an AccuStick.
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Unlock the locking string before advancing the wire. Many biliary catheters have a Cope loop or locking mechanism. Failure to unlock before advancing the exchange wire will prevent the catheter from straightening, making smooth removal impossible.
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Exchange Schedule & Documentation
Scheduled Intervals
- Internal-external biliary drain: Every 3 months
- External-only biliary drain: Every 3 months
Early Exchange Indications
- Fever + rigors suggesting cholangitis
- Bloody drain output
- Bilirubin rising despite apparently patent drain
- Patient reporting drainage stoppage or decreased output
- Catheter visible on imaging to be malpositioned
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- SIR quality improvement guidelines for percutaneous biliary interventions
Primary References
- Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol. 2010;21(6):789–795.
- Lee MJ, Mueller PR, Saini S, et al. Percutaneous dilatation of benign biliary strictures: single-session therapy with general anesthesia. AJR Am J Roentgenol. 1991;157(6):1263–1266.
- Covey AM, Brown KT. Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol. 2008;11(1):14–20.