CME REVIEW Interventional radiology plays a key role in diagnosing, managing, and determining the prognosis of pa- tients with liver pathology. Together with clinical and laboratory findings (aspartate or alanine aminotransfer- ase, alkaline phosphatase), patholog- ical evaluation following image-guid- ed liver biopsy allows for histological characterization of disease. 1 Indications for Liver Biopsy Image-guided biopsy is useful in a number of ways with respect to diagnosing, treating, and man- aging patients with liver condi- tions. These include: • Differentiating drug-related hepa- totoxicity from autoimmune hep- atitis in the absence of previous hepatotoxicity warnings. 2 • Assisting in the diagnosis of he- reditary conditions such as Wilson disease, A1-antitrypsin-1 deficiency, and hereditary hemochromatosis. In Wilson disease, a hepatic copper content > 250 μg/g has been reported as the best biochemical evidence for Percutaneous and Transvenous Liver Biopsy Amir Hossein Mostafavi Sterabadi, BS; Hassan Anbari, MBChB; Minhaj S. Khaja, MD, MBA; Baljendra S. Kapoor, MD Affiliations: Anne Burnett Marion School of Medicine at TCU, Fort Worth, Texas (Mr Sterabadi); Division of Vascular and Interventional Radiology; Department of Radiology; University of Michigan Medical Center, Ann Arbor, Michigan (Drs Anbari, Khaja, Kapoor). Disclosures None. Prior publication: This manuscript has not been previously presented or published. diagnosis; 3 hereditary hemochroma- tosis can be diagnosed based on iron distribution within the tissue. 4 • Identifying drug-induced fibro- sis secondary to treatment with methotrexate; pre- and post-treat- ment biopsies, as well as follow-up biopsies, are recommended for patients aſter each accumulated dose of 1.5 grams. 2 • Grading and staging of non-alco- holic fatty liver disease (NAFLD), alcoholic liver disease, chronic hep- atitis, and many other associated illnesses. 2 In chronic hepatitis C (or persistent hepatitis B) patients, bi- opsy results help to determine the need for antiviral therapy. It is also recommended that biopsies be ac- quired every two to three years for assessment of disease progression. 2 Based on recommendations by the American Association for the Study of Liver Disease (AASLD), the diagnostic and prognostic ability of liver biopsy for advanced fibrosis in patients with chronic hepatitis C infection cannot be achieved by noninvasive testing alone. 2 • Staging for prognostic values and offering insight into physiological response to drug treatment and management regimens. 2 • Assessing the acuity and degree of rejection In the setting of liver transplantation. 2,5 • Identifying unexplained abnormal- ities of liver testing or hepatomeg- aly, hepatic neoplasms and lesions, infections, unexplained cholestasis, metabolic and genetic disorders, and fever of unknown origin. 2 Percutaneous Liver Biopsy Percutaneous liver biopsy (PLB) has been used to identify hepatic pa- thology since the first core biopsy was performed in 1880 by Paul Ehrlich in Germany and was adapted as a staple in histological liver diagnostics in 1957 by Menghini. 6,7 The technical aspects of PLB differ from that of transvenous liver biopsy (TVLB). In the setting of non-image-guided PLB, the area of maximum dullness can be identified by percussion over the right hemithorax between the sixth and ninth intercostal space. 8 Image-guided PLB has largely replaced the non-image-guided PLB and is usually performed under ultrasound guidance. However, CT and other modalities are also implemented. Image-guided PLB helps to evaluate for the presence of overlying organs and vascular lesions at risk for bleeding, such as hepatic hemangioma (Figure 1). 8 The potential complications asso- ciated with PLB range from pain and transient hypotension to intraperi- toneal or intrahepatic hemorrhage, ©Anderson Publishing, Ltd. All rights reserved. Reproduction in whole or part without express written permission is strictly prohibited. CME DETAILS ON PAGE 7 Applied Radiology 8 September / October 2023