TRANSJUGULAR LIVER BIOPSY (TJLB) IN THE MODERN ERA: SAFETY, TECHNICAL EVOLUTION AND DIAGNOSTIC IMPACT IN A REAL-WORLD TERTIARY COHORT

Background: Trans-jugular liver biopsy (TJLB) is traditionally indicated in patients with advanced liver disease and contraindications to percutaneous biopsy. While historically valued for its safety in coagulopathic settings, its role has expanded to include indications such as acute hepatitis and liver involvement in hematological disorders. In complex clinical scenarios, the combination of histological and hemodynamic assessment (hepatic venous pressure gradient, HVPG) may provide a comprehensive diagnostic approach. This single-center retrospective study aimed to evaluate the safety, technical evolution, and diagnostic impact of TJLB in a real-world tertiary hepatology and hemodynamics setting. Methods: Clinical, hemodynamic, procedural, and histological data from 437 patients who underwent TJLB between 2012 and 2025 at our Hepatic Hemodynamic Laboratory were retrospectively analyzed. Statistical analyses included Firth’s penalized logistic regression to identify predictors of procedural complications, as well as factors associated with sample fragmentation and diagnostic yield. Diagnostic yield was defined as the ability of the procedure to confirm or modify (unexpected diagnosis) the initial clinical suspicion. Results: The cohort had a median age of 58 years (IQR 15) and was predominantly male (62%). Ascites was present in 36% of patients, esophageal varices in 53%, and clinically significant portal hypertension (CSPH) in 57%, with a mean HVPG of 12 ± 8 mmHg. Severe thrombocytopenia (<50,000/mm³) was observed in 13% of cases. Main indications included acute hepatitis (7%), hematological disorders (15%), and suspected porto-sinusoidal vascular disease (PSVD, 13%). TJLB achieved histological adequacy in 91.5% of cases. The overall complication rate was low (5.0%), consisting mainly of minor events, with no procedural mortality. Impaired renal function (elevated creatinine and dialysis) was the only clinical factor significantly associated with complications. A significant temporal improvement was observed: the use of 18-gauge needles in earlier years was associated with increased sample fragmentation and lower adequacy (p<0.001), which improved after transition to 19-gauge Tru-Cut needles. Fragmentation was not associated with fibrosis stage or CSPH. The introduction of real-time ultrasound guidance allowed avoidance of routine intravenous fentanyl, improving patient tolerance without compromising safety or efficacy. Notably, nearly 20% of patients with hematological disorders showed hepatic infiltration. Among patients with acute hepatitis, the most common suspected etiologies were autoimmune-related (23%) and alcohol-related (19%). Despite worse liver and renal function and higher inflammatory markers, these patients did not experience higher complication rates and maintained comparable sample quality and adequacy. Conclusion: TJLB is a safe and highly effective procedure, even in complex clinical settings. Technical advancements, including the transition to 19 G Tru-Cut needles and real-time ultrasound guidance, have improved sample quality and patient tolerance. In selected populations, the combined histological and hemodynamic approach can significantly influence clinical management.