Percutaneous Trans-Hepatic Embolization of an Iatrogenic Extra-Hepatic Pseudoaneurysm of the Right Hepatic Artery in a Patient With Previous Occlusion of the Proper Hepatic Artery: An Endovascular Procedure to Avoid a Difficult Surgical Repair

Introduction

Hepatic pseudoaneurysm (PsA) formation is a possible complication of liver biopsies or percutaneous biliary procedures, usually treated by minimally invasive interventional procedures using an endovascular and/or percutaneous trans-hepatic approach.^1-4 We present a case of successful percutaneous trans-hepatic embolization of an iatrogenic extra-hepatic PsA of the right hepatic artery (RHA) in a patient with previous occlusion of the proper hepatic artery (PHA) using a mixture of Lipiodol® (Guerbet, Roissy, France) and cyanoacrylate-based glue (Glubran®2) (GEM, Italy) under combined fluoroscopic and ultrasonographic guidance.

Methods

A 73-year-old man known to suffer from autoimmune cholangitis underwent percutaneous transhepatic biliary drainage in another hospital, after several presentations with fever and jaundice associated with elevation of serum alkaline phosphatase and total bilirubin. A few days after his discharge from hospital, the patient was re-admitted with fever and haemobilia. Computed tomography showed an iatrogenic extra-hepatic PsA of the RHA. Endovascular embolization was attempted resulting in coil embolization of the proper hepatic artery (PHA) without occlusion of the PsA lumen. The patient was referred to our hospital. Computed tomography confirmed the occlusion of the PHA and the persistence of the iatrogenic PsA (27 mm diameter in the axial plane) in the extra-hepatic portion of the RHA (Figure 1). The next day a diagnostic arteriogram was performed. Celiac axis arteriography confirmed occlusion of the PHA, persistence of the RHA PsA and multiple small collaterals arising from the accessory left hepatic artery refilling the RHA branches and the PsA (Figure 2). Attempted selective catheterization of these vessels was unsuccessful due to the tortuosity and very small caliber of the intra-hepatic collaterals. The procedure was thus abandoned given the patient’s stable hemodynamic status. Surgical repair due to the presence of coil occlusion of the PHA, was considered at high risk in consideration of the patient’s old age, pre-existing autoimmune cholangitis and haemobilia, although feasible as a last option. The next day percutaneous trans-hepatic embolization under combined fluoroscopic and ultrasonographic guidance was attempted, with the precautionary preparation of an operating room on standby. Using a LOGIQ 7 Ultrasound scanner (GE Healthcare, Milwaukee, WI) equipped with a 3.5-MHz transducer, percutaneous trans-hepatic puncture of the PsA, with an 18-gauge needle, under ultrasound and fluoroscopic guidance, was performed (Figure 3). Through the 18-gauge needle, the PsA was completely embolized using 3 mL of a mixture of ethyl esters of iodized fatty acids of poppy seed oil (Lipiodol®) and cyanoacrylate-based glue (Glubran®2), in a 1:2.5 (Glubran®2: Lipiodol®) ratio.^5,6 Dextrose (5%) was used to flush the needle before and after the administration of glue to prevent its polymerization within the needle. Computed tomography performed after the procedure showed the complete occlusion of the pseudoaneurysm (Figure 4). ALT (22 U/L), AST (13 U/L), total (0.7 mg/dL) and direct bilirubin (0.5 mg/dL) levels were normal the day after the embolization. The patient was discharged from our hospital in good general condition 4 days after the procedure.

OPEN IN VIEWER

Figure 1.

CT showing the iatrogenic PsA (27 mm diameter in the axial plane) in the extra-hepatic portion of the RHA.

OPEN IN VIEWER

Figure 2.

Celiac axis arteriography confirmed the occlusion of the PHA, and the persistence of the RHA PsA multiple small collaterals from the accessory left hepatic artery refilling the RHA branches and the PsA.

OPEN IN VIEWER

Figure 3.

Percutaneous trans-hepatic puncture of the PsA, with an 18-gauge needle, under ultrasound and fluoroscopic guidance.

OPEN IN VIEWER

Figure 4.

CT scan after the procedure, showed the complete occlusion of the pseudoaneurysm.

Discussion

Hepatic artery PsA is an uncommon but potentially lethal complication of hepatic, biliary, and pancreatic interventions. ⁷ Major complications associated with biliary procedures are reported in 5–7% of cases with arterial bleeding reported in approximately 2% of cases resulting in most cases in haemobilia. ⁸ The endovascular approach is usually the initial choice of treatment of a PsA, ⁹ however, in our patient, this was impossible because of the previous occlusion of the PHA.

Surgical intervention with ligation of the bleeding vessel is considered for unstable patients and when embolization fails or is not feasible. A low number of blood transfusions required prior to angiography was associated with better survival, which may simply reflect hemodynamic stability from a less severe pseudoaneurysmal rupture. ¹⁰

Percutaneous transhepatic PsA embolization, using a cyanoacrylate-based glue or coils, has already been described in the literature for intra-hepatic PsA^1,2,3; in our case the technique was effective also in an extra-hepatic PsA, the latter having a major risk of rupture and consequent hemoperitoneum when compared to intra-hepatic PsA. In our patient, we decided to perform the embolization using a mix of Lipiodol® and Glubran®2. Coils could also be used, ¹⁰ however, we decided to use a mix of Lipiodol® and Glubran®2 because of the fast polymerization time of the glue allowing the complete occlusion of the PsA in few seconds, thus eliminating the risk of coil migration, reducing the risk of PsA rupture and avoid a difficult surgical repair.