Intra-hepatic arterial pseudoaneurysm causing life-threatening upper gastrointestinal bleed after removal of biliary drainage catheter
1 Interventional Radiology Centre, Singapore General Hospital, Singapore
2 Department of General Surgery, Singapore General
Hepatic artery pseudoaneurysms are an uncommon
complication of percutaneous biliary drainage catheter insertion. The authors
report a case of a hepatic artery pseudoaneurysm following percutaneous
internal-external biliary drain insertion. This led to massive haemobilia when
the catheter was removed and presented clinically as life-threatening upper
gastrointestinal bleed. The clinical and imaging manifestations are discussed
along with the management of the patient. � 2009 Biomedical Imaging and
Intervention Journal. All rights reserved.
Keywords: Hepatic artery pseudoaneurysms, internal-external
biliary drain insertion, upper gastrointestinal bleed, Whipple�s operation,
There are various causes of massive haematemesis with
peptic ulcer disease and variceal haemorrhage being the more common underlying
conditions. Haemobilia is a less well-known cause of critical haematemesis .
The authors report a case of haemobilia arising from a hepatic artery
pseudoaneurysm, which developed as a complication of percutaneous biliary
drainage catheter insertion, leading to massive upper gastrointestinal
haemorrhage and collapse of the patient when the catheter was removed. This
case illustrates a number of important clinical points namely the value of early
clinical recognition of the underlying complication, the useful role of CT
angiography in detection and management of hepatic artery pseudoaneurysms, the
apparent lack of correlation between lesion size and clinical presentation and
the role of endovascular treatment in management of these patients.
A 54-year-old, previously healthy, male patient
investigated for progressive jaundice was found to have a carcinoma of head of
pancreas with dilated proximal bile ducts. The patient developed cholangitis
and an 8F internal-external biliary drainage catheter was placed, through the
left intra-hepatic bile duct approach.
He subsequently underwent a Whipple�s operation 3 days
later. During the operation, the tumor was found to be adherent to the superior
mesenteric artery (SMA) with partial venous invasion at the confluence of
superior mesenteric vein (SMV) with portal vein (PV). The tumor was dissected
off the SMA, sleeve resection of the SMV and PV junction was performed and the
defect closed with primary reconstruction. The biliary drainage catheter was
left as a stent across the hepatico-jejunal anastomosis.
Postoperative recovery was uneventful. Two weeks
post-surgery, he was brought into the angiography suite for cholangiogram
through the existing left biliary drainage with a view to catheter removal,
prior to discharge from the hospital.
The cholangiogram revealed a patent anastomosis with good
drainage into bowel (Figure 1). The biliary drain was removed on the
angiographic table upon completion of the cholangiogram. Minimal oozing of
blood from the drainage catheter entry site on the skin in the midline was
observed, which stopped with compression.
While preparation was being done to transfer the patient
from the angiographic table, he became increasingly unwell. Within ten minutes
of tube removal, there was an episode of massive haematemesis. He became
increasingly hypotensive and tachycardic, and collapsed. Emergency
resuscitation and intubation was performed, with the patient urgently evacuated
to the emergency operating room. He was stabilised while preparations were
being made to operate on him again. One of the major possibility considered for
the patient�s presentation was bleeding from the breakdown at the portal venous
reconstruction site. While this was being done, emergent endoscopy and
ultrasound of abdomen was performed. There was no source of bleeding identified
on endoscopy, with no free fluid in the abdomen or pelvis.
As the patient stabilised with blood transfusion and
continued to remain stable with active resuscitative measures, massive
haemobilia from pseudoaneurysm was considered, especially since there was no
free fluid in the abdomen or pelvis on ultrasound. CT angiogram was performed
in order to identify the source of bleeding more accurately before more
invasive intervention was undertaken.
The arterial phase of CT angiogram revealed a 1 cm
pseudoaneurysm arising from one of the intraparenchymal left hepatic artery
branches with active contrast extravasation into an adjacent bile duct (Figure 2a
On the basis of imaging and because of the intrahepatic
location of the lesion, a decision was made to manage the lesion through an
endovascular approach. Selective catheterisation and embolisation of the lesion
was performed with microcoils with complete angiographic exclusion of the
pseudoaneurysm (Figure 3a and 3b). The patient recovered well over the
next few days and was discharged from the hospital 10 days later.
Biliary drainage catheter insertion is a well-recognised
cause of haemobilia related to underlying vascular complication of the
procedure . Clinically, suspicious signs of presence of these
complications include blood stained bile in the drainage bag, oozing of blood
around the catheter entry site on the skin, significant gastrointestinal
bleeding and falling haemoglobin levels, and bleeding from the tract at the
time of tube change or removal .
The acute presentation in this patient with massive
haemobilia and haematemesis leading to collapse is quite unusual, especially
since the bile draining into the connecting bag prior to removal of the
catheter did not suggest prior bleeding. The patient had also recovered well
from surgery and there were no risk factors such as deranged clotting profile.
Intrahepatic arterial injury related to biliary drainage
procedures have been reported to have an incidence of about 2% , with
suggestion of the complication being higher in biliary drainage catheters
inserted from the left compared to the right hepatic lobe . However, with
studies documenting higher patient comfort and acceptability for left hepatic
lobe interventions , and technically easier direct image-guided approach,
left intrahepatic duct is the preferred option for biliary access and drain
insertion in distal lesions of the biliary tree with communicating right- and
left-sided ducts. Certainly, this is the preferred approach at the authors'
In this patient, an experienced operator placed the left
internal-external biliary drain following biliary access into segment 3 bile
duct under ultrasound guidance. No difficulty was encountered during the
procedure and the drain was left inside the patient for 18 days. The drainage
catheter caused injury to the wall of the adjacent left hepatic artery, and
tamponaded the site, until its removal led to massive bleeding.
The case emphasises the importance of clinical acuity and
the extremely useful role of CT angiography in evaluating these patients. CT
angiogram has a well-established role in patients presenting with
gastrointestinal haemorrhage not detected by endoscopy, especially when the
patient is hemodynamically stable [6, 7]. CT angiogram not only detected the
vascular abnormality accurately in this case, but was also pivotal to the
decision for endovascular intervention. The intra-hepatic pseudoaneurysm and
the active extravasation of contrast into the biliary duct were well
identified. Reviewing the thin section images carefully at the time of the scan
is important to establish an accurate diagnosis. Also of clinical interest is
the apparent discordance between the size of the lesion and the clinical
presentation of the patient.
Hepatic pseudoaneurysms can be effectively treated by the
endovascular approach [8, 9]. Embolisation is relatively safe and can be
performed successfully in the majority of these patients. Surgery has minimal
role in such cases except in patients with aberrant or extremely tortuous
vessels where the target lesion cannot be accessed.
Various embolisation agents such as coils, N- butyl
cyanoacrylate (NBCA), gelfoam and polyvinyl alcohol (PVA) particles are
available for treating these lesions. In the authors' experience, coils are
highly effective and provide safe, durable embolisation . In embolizing
pseudoaneurysms, care should be taken to occlude both the �front and back
doors�, to prevent the risk of retrograde recanalisation of the pseudoaneurysm
at a later stage. A few accurately placed microcoils are usually sufficient for
effectively occluding pseudoaneurysms.
In the post-embolisation period, patients frequently
stabilize haemodynamically soon after the procedure. Isolated episodes of
further gastrointestinal haemorrhage of altered blood contents are not unusual
in the post- procedure period, and should not be of concern as long as the
haemodynamic parameters are stable.
In conclusion, biliary drainage catheter related
iatrogenic hepatic arterial injury can be life threatening. A high index of
suspicion ensures prompt diagnosis and management of these patients.
Figure 1 Cholangiogram performed through retained left internal-external biliary drain 2 weeks post-procedure shows patent anastomosis with free drainage of contrast into small bowel loops.
Figure 2 (a) CT angiogram shows 1 cm left hepatic artery pseudoaneurysm (arrow) within left lobe of liver. (b) CT angiogram immediately below the above lesion demonstrates active extravasation of contrast in the adjacent bile duct (arrow).
Figure 3 (a) Selective angiogram confirms a small pseudoaneurysm (arrow) arising from segment 3 hepatic artery. (b) Post-embolisation angiogram demonstrates complete exclusion of the pseudoaneurysm.
Hsu KL, Ko SF, Chou FF et al. Massive hemobilia. Hepatogastroenterology 2002; 49(44):306-10.
Mitchell SE, Shuman LS, Kaufman SL et al. Biliary catheter drainage complicated by hemobilia: treatment by balloon embolotherapy. Radiology 1985; 157(3):645-52.
L'Hermine C, Ernst O, Delemazure O et al. Arterial complications of percutaneous transhepatic biliary drainage. Cardiovasc Intervent Radiol 1996; 19(3):160-4.
Rivera-Sanfeliz GM, Assar OS, LaBerge JM et al. Incidence of important hemobilia following transhepatic biliary drainage: left-sided versus right-sided approaches. Cardiovasc Intervent Radiol 2004; 27(2):137-9.
Tan KT, Rajan DK, Kachura JR et al. Pain after percutaneous liver biopsy for diffuse hepatic disease: a randomized trial comparing subcostal and intercostal approaches. J Vasc Interv Radiol 2005; 16(9):1215-9.
Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol 2007; 62(10):938-49.
Jaeckle T, Stuber G, Hoffmann MH et al. Detection and localization of acute upper and lower gastrointestinal (GI) bleeding with arterial phase multi-detector row helical CT. Eur Radiol 2008; 18(7):1406-13.
Savader SJ, Trerotola SO, Merine DS et al. Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy. J Vasc Interv Radiol 1992; 3(2):345-52.
Rosen RJ, Rothberg M. Transhepatic embolization of hepatic artery pseudoaneurysm following biliary drainage. Radiology 1982; 145(2):532-3.
Taneja M, Tan KT. Renal vascular injuries following nephron-sparing surgery and their endovascular management. Singapore Med J 2008; 49(1):63-6.
|Received 12 April 2009; received in revised form 8 June
2009, accepted 9 June 2009
Correspondence: Interventional Radiology Centre, Singapore General Hospital, Outram Road, Singapore 169608. E-mail: email@example.com (Manish Taneja).
Please cite as: Taneja M, Lo R, Sebastian MG, Chow PKH,
Intra-hepatic arterial pseudoaneurysm causing life-threatening upper gastrointestinal bleed after removal of biliary drainage catheter, Biomed Imaging Interv J 2009; 5(3):e20