Transarterial Embolization of a Hepatic Pseudoaneurysm with Hemobilia

Laparoscopic cholecystectomy has replaced open surgery for cholelithiasis because it has lesser complications and shorter recovery time; however, iatrogenic biliary and vascular injuries still occur in 0.3 to 1.0 % of the patients [1-3]. A symptomatic pseudoaneurysm may arise in the early postoperative period or as late as 120 days after surgery [4].

The pathogenesis of a pseudoaneurysm of the hepatic and cystic arteries probably relates to disruption of the arterial wall related to mechanical and/or thermal vascular injury due to electrocautery and or to bile leakage with chemical injury related to surgical dissection at the infundibulum of the gallbladder [4-11]. If the pseudoaneurysm communicates with the biliary tree, the patient will present with hemobilia.

Hemobilia presents the triad of Quincke; gastrointestinal bleeding, abdominal pain and jaundice. The intensity of the symptoms may vary from mild pain, anemia with or without slight jaundice to massive, life threatening gastrointestinal bleeding [12-14]. The probability and severity of the bleeding correlates directly with the size of the pseudoaneurysm [9,12-15].

A recent surgical history and the clinical picture of hemobilia should prompt to endoscopy with retrograde endoscopic cholangiography, however it is often inconclusive [6,16]. Imaging studies such as Spiral CT and or ultrasound may reveal signs of the aneurysm [10,17-21]. The gold standard for the diagnosis is a visceral angiography [1,13,14,22].

Transarterial embolization is the first therapeutic option in case of a severe or recurrent bleeding and has a success rate of 80 to 100% with a few complications [1,14,22,23]. In case of compression of the bile duct or a fistula or failure from embolization, open surgery should be performed to ligate the affected artery [17]. In our patient, surgical ligature of the right hepatic artery was presumably performed, probably a branch, without occluding the main trunk of the RHA that harbored the pseudoaneurysm which led to recurrent bleeding that prompted embolization. Among the limitations of embolization are anatomical variations of the hepatic artery and recanalization of the aneurysm [24]. Hepatic artery embolization risks are hepatobiliary necrosis, bleeding, abscess formation and gallbladder fibrosis [24]. In case of embolization failure, open surgery for hemobilia is indicated [24,25].

In the scenario of hemobilia after laparoscopic cholecystectomy, a hepatic artery aneurysm must be strongly suspected, angiographically confirmed and embolized. If embolization fails, surgical intervention should be performed. This report aims to contribute to the awareness of the surgical community on the diagnosis and treatment of this infrequent situation and to highlight the relevance of endovascular embolization.

Among the therapeutic alternatives to occlude an aneurysmal sac, we have the reconstructive technique which uses metal coils or coated stents, and the deconstructive technique in which it is embolized by injecting occluding substances.

We decided for the second option before the difficult geometry of the celiac trunk that prevented the advance of our microcatheter guide towards the RHA and we used n-butyl cyanoacrylate plus lipiodol for its wide availability and lower cost in our environment as well as for our experience with this mixture in thousands of brain and systemic injuries. Particulate materials such as PVA, gel foam and others can only occlude the distal arteriolocapillary bed, but not large arteries, such as the RAE, which can increase the pressure of the stump and induce new hemorrhages.