04:12 PM Abstract No. 81 Comparing transfemoral transcaval and transjugular transvenous core-needle liver biopsies in patients with Fontan-associated liver disease

The Fontan procedure enables prolonged survival of patients with single-ventricle physiology. As these patients progress to adulthood, Fontan-associated liver disease (FALD) is becoming more prominent. Liver biopsy remains the standard for diagnosis of FALD. Transabdominal liver biopsy carries risk for bleeding in these patients with congestive hepatopathy and limited cardiac reserve. Transjugular liver biopsy (TJLB) may be difficult due to complex Fontan venous anatomy. In addition, as FALD may have heterogenous involvement of the liver, tissue samples adjacent to the hepatic veins where congestion can be pronounced may not be representative of global liver disease. Transfemoral transcaval liver biopsy (TFTC) has been described as an alternative to TJLB and may be suitable in these patients. This study investigates the safety, efficacy, outcomes, and utility of TFTC in comparison to TJLB in Fontan patients. This was a single-center, retrospective review of 20 transvenous liver biopsies (55% male; median age 23y, range 12-43) occurring between 2011 and 2018 in 19 patients with Fontan anatomy. Procedural complications were classified according to SIR guidelines. 13 (65%) procedures were done via TFTC route and 7 (35%) via TJLB route, yielding 1-5 core biopsy samples. Technique was primarily chosen by pre-existing venous access or patient anatomy. 18 of 20 biopsies (90%) occurred in conjunction with cardiac angiography procedures. Technical success was achieved in all cases. 3 specimens (15%, 1 TFTC and 2 TJLB) were suboptimal or fragmented, however all resulted in histopathological diagnoses. Portal manometry was obtained in 17/20 biopsies (85%, 5/7 TJLB, 12/13 TFTC). One patient experienced liver hemorrhage following TJLB requiring blood transfusion and intensive care. There were no major complications after TFTC. In comparison to the TJLB technique, TFTC is safe and effective in Fontan patients. It avoids traversing the Fontan shunt and acquires samples from central portions of the liver that are not adjacent to the hepatic veins, which may be desirable. TFTC should be considered, and may be the preferred technique in the workup of FALD in Fontan patients.