Fig. 2

Step by step process of primary percutaneous stenting. Ultrasound-guided access to the biliary tree is obtained (A); and fluoroscopy confirms catheter placement in the bile duct (B); Contrast injection visualizes the biliary anatomy and obstruction (C); A guidewire is advanced, carefully passing the tumor while avoiding the ampulla (D); Balloon dilation is performed to widen the stricture (E); and stent insertion is performed, followed by post-dilation with two balloon catheters (F); Bilateral uncovered self-expanding metallic stents are deployed (G); and the puncture tract is sealed with Avitene (H)