Fig. 2. Patient with history of orthotopic liver transplant with complex biliary obstruction. Previous right percutaneous transhepatic biliary drainage and left external biliary drain in place. (A) Radiograph shows a sheath placed using right biliary access (arrow), the jejunum is opacified with contrast is punctured with a Chiba needle and a wire is advanced. Note previously placed left hepatic external drain (curved arrow). (B) Radiograph shows three 10 Fr internal double mushroom stents (black arrows) placed across the anastomotic occlusions, each into a major bile duct branch. Right transhepatic access then removed and coils placed in tract (white block arrow). Jejunostomy tube left in place as access for future stent exchange (curved arrow). Left biliary drain was later removed. (C) After a later reintervention patient developed dilated loops of small bowel and mesenteric edema consistent with a closed loop small bowel obstruction and went on to laparotomy and segmental bowel resection. Cone-beam computed tomography demonstrates a Chiba needle traversing the anterior abdominal wall musculature (white arrow), accidentally crossing another loop of small bowel (dashed white arrow) with the tip in a loop of contrast-filled small bowel (black arrow). This was noted retrospectively after performing multiplanar reformatting.
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