The integration of CT and fluoroscopy within a single interventional environment provides several important advantages compared to conventional PTBD workflows. Aerobilia as basic requirement acts as an intrinsic negative contrast medium and markedly enhances visualization of even non-dilated bile ducts. This effect is particularly pronounced in left-sided ducts, which are more anteriorly positioned and therefore more readily accessible during image-guided intervention. Improved duct conspicuity allows the operator to identify small-caliber targets that would otherwise require multiple puncture attempts under fluoroscopy alone.

Beyond enhanced visualization, real-time CT fluoroscopy enables continuous monitoring and adjustment of the needle trajectory during hepatic advancement. Deviations can be corrected immediately, reducing the likelihood of extra-ductal placement, parenchymal perforation, or vascular injury. This contributes to a more controlled access pathway, especially in patients with collapsed or narrow duct systems.

A further technical advantage lies in procedural workflow efficiency. Because fluoroscopy and CT operate on a shared gantry and table, modality switching occurs without patient repositioning. This eliminates the logistical break inherent to conventional CT-then-fluoroscopy sequences and prevents guidewire displacement during patient transfer. As a result, the procedure proceeds without interruption, reducing latency between puncture, wire insertion, and catheter deployment while maintaining spatial instrument stability.

The use of angio-CT in PTBD represents a significant advancement, particularly for patients with complex biliary anatomy or challenging pathologies [1, 2, 4]. If an angio-CT is available, it should be considered for patients with aerobilia and bile leakage. This approach ensures safe and efficient biliary access while seemingly reducing complications.

This pilot study evaluates the feasibility and safety of the hybrid angio-CT technique. While ultrasound guidance represents an established alternative, it is inherently limited by its dependence on duct visibility, operator skill, and acoustic window quality — factors that are often compromised in non-dilated or post-surgical biliary systems. Availability of hybrid angio-CT systems is limited and broad implementation requires suitable infrastructure. Therefore, this technique currently applies predominantly to centres where such systems are available. Ultrasound-guided access may also be possible when targeting echogenic intraductal air, and angulation of the needle along portal radicles can support duct entry even without CT guidance. In biliary-enteric anastomosis, reflux pneumobilia frequently increases ductal prominence and improves visualisation, independent of hybrid imaging. This study is limited by its small sample size and lack of a control group. Larger, randomized studies are needed to validate the findings and compare outcomes with conventional techniques. This work is a case-series without a comparison cohort; conclusions regarding superiority over conventional PTBD is limited.