Successful Endovascular Management of Pseudoaneurysm following Transarterial Chemoembolization: A Case Report.

Background and Objectives: Transarterial chemoembolization (TACE) is a widely accepted treatment for hepatocellular carcinoma (HCC). Regarding TACE, arterial injuries, such as hepatic artery spasm or dissection, can also occur, although pseudoaneurysms are rare. We report a case of pseudoaneurysm following TACE. Materials and Methods: A 78-year-old man had been undergoing TACE for HCC in segment 8 of the liver for the past 5 years, with the most recent TACE procedure performed approximately 1 month prior. He presented to the emergency department with melena that persisted for 5 days. Computed tomography revealed a pseudoaneurysm in the S8 hepatic artery with hemobilia. Results: the pseudoaneurysm was successfully treated by N-Butyl-cyanoacrylate glue embolization. Conclusions: In patients that have undergone TACE presenting with melena and hemobilia identified on CT, consideration of hepatic artery pseudoaneurysm is crucial. Such cases can be safely and effectively treated with endovascular managements.

A rare incidence of a hepatic artery pseudoaneurysm following plastic biliary stent insertion.

Hepatic artery pseudoaneurysms have been reported to occur in approximately 1% of cases after metal stenting for malignant biliary obstruction. In contrast, only a few cases have been reported as complications after plastic stenting for benign biliary disease. We report a 61-year-old man with cholangitis who presented with a rare complication of hemobilia after implantation of 7 Fr double pigtail plastic biliary stents. No bleeding was observed approximately one month after biliary stent tube removal. Contrast-enhanced CT scan revealed a circularly enhanced lesion (5 mm in diameter) in the arterial phase at the tip of the previously inserted plastic bile duct stent. Color Doppler ultrasonography enhanced the lesion and detected arterial blood flow inside. He was diagnosed with a hepatic artery pseudoaneurysm. However, he had no risk factors such as prolonged catheterization, severe cholangitis, liver abscess, or long-term steroid use. Superselective transarterial embolization using two metal microcoils was successfully completed without damage to the surrounding liver parenchyma. If hemobilia is suspected after insertion of a plastic bile duct stent, immediate monitoring using contrast-enhanced computed tomography or Doppler ultrasonography is recommended.

Multidisciplinary management of high-grade pediatric liver injuries.

OBJECTIVE: To present our experience of multidisciplinary management of high-grade pediatric liver injuries. INTRODUCTION: Pediatric high-grade liver injuries pose significant challenge to management due to associated morbidity and mortality. Emergency surgical intervention to control hemorrhage and biliary leak in these patients is usually suboptimal. Conservative management in selected high-grade liver injuries is now becoming standard of care. Management of hemobilia due to pseudoaneurysm formation and traumatic bile leaks requires multidisciplinary management. METHODS: A retrospective review was undertaken for patients presenting with blunt liver injuries at two tertiary care centers in Karachi, Pakistan, from March 2021 to December 2022. Twenty-eight patients were identified, and four patients fulfilled the criteria for grade 4 and above blunt liver injury during this period. RESULTS: One case with grade 4 liver injury developed hemobilia on 7th day of injury. He required two settings of angioembolization but had recurrent leak from pseudoaneurysm. He ultimately needed right hepatic artery ligation. Second patient presented with massive biliary peritonitis 2 days following injury. He was managed initially with tube laparostomy followed by ERCP and stent placement. The third patient developed large hemoperitoneum managed conservatively. One case with grade 5 injury expired during emergency surgery. CONCLUSION: Conservative management of advanced liver injuries can result in significant morbidity and mortality due to high risk of complications. Trauma surgeons need to have multidisciplinary team for management of these patients to gain optimal outcome.

A fatal case of massive hemobilia caused by invasive pancreatic cancer with median arcuate ligament syndrome: A case report.

INTRODUCTION: In median arcuate ligament syndrome (MALS), the celiac artery is compressed, causing an arcade to develop in the pancreatic head, leading to ischemic symptoms and aneurysms. PATIENT CONCERNS: The patient was diagnosed with borderline resectable pancreatic cancer (PC) and MALS. Endoscopic biliary drainage with a covered metal stent (CMS) was performed for the obstructive jaundice. After the jaundice improved, a modified FOLFIRINOX regimen was initiated. Several days later, cardiopulmonary arrest occurred after hematemesis occurred. Cardiopulmonary resuscitation was performed, his blood pressure stabilized, and emergent upper endoscopy was performed. The CMS was dislodged and active bleeding was observed in the papillae. The CMS was replaced, and temporary hemostasis was achieved. Contrast-enhanced computed tomography revealed a diagnosis of extravasation from the posterior superior pancreaticoduodenal artery (PSPDA) into the biliary tract. Transcatheter arterial embolization was performed. However, the patient was subsequently diagnosed with hypoxic encephalopathy and died on day 14 of hospitalization. DIAGNOSIS: Biliary hemorrhage due to invasion of pancreatic cancer from the PSPDA associated with MALS. INTERVENTION: None. OUTCOMES: Biliary hemorrhage from the PSPDA was fatal in the patient with invasive PC with MALS. LESSONS: Since MALS associated with PC is not a rare disease, the purpose of this study was to keep in mind the possibility of fatal biliary hemorrhage.

[Hemobilia as a sign of arterio-biliary fistula]. / Gemobiliya kak proyavlenie arteriobiliarnoi fistuly.

Hepatic artery aneurysms (HAA) are rare (20% of all visceral arteries). Most often, HAAs are asymptomatic and detected at autopsy. However, their ruptures and/or bleeding following pressure ulcers in visceral gastrointestinal organs are a significant clinical and diagnostic problem. We present 2 patients with obstructive jaundice and hemobilia. Diagnostics revealed aneurysm of the right hepatic artery with arterio-biliary fistula. Life-threatening hemobilia is a consequence of HAA rupture into biliary system. Endovascular approach is preferable for HAA without clinical manifestations. Awareness of this disease is important for early detection and active surgical intervention before possible complications.

Late-onset hemobilia due to pseudoaneurysm rupture after endoscopic ultrasound-guided hepaticogastrostomy.

We report the case of a 65-year-old man who experienced hemobilia due to rupture of a pseudoaneurysm of the left hepatic artery after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). The patient was diagnosed with pancreatic cancer and underwent endoscopic retrograde cholangiopancreatography for obstructive jaundice. Biliary drainage was converted to EUS-HGS due to tumor invasion in the superior duodenal angle. A partially covered metal stent was placed in the B3 intrahepatic bile duct. The procedure was completed without early complications, but 50 days later, the patient developed fever, elevated hepatobiliary enzymes, and shock. Contrast-enhanced computed tomography (CT) showed that the hepatic end of the HGS stent had moved slightly toward the stomach compared to the previous CT. A 6-mm pseudoaneurysm was also observed near the A3 and A4 branches of the left hepatic artery, coinciding with the hepatic end of the EUS-HGS stent. Hemostasis was achieved with coil embolization. Biliary hemorrhage due to rupture of a pseudoaneurysm should be considered in the differential diagnosis of biliary obstruction accompanied by bleeding after EUS-HGS.

Hemobilia in the setting of cystic artery pseudoaneurysm secondary to type I Mirizzi syndrome.

Hemobilia is an uncommon diagnosis and is often not suspected in the absence of recent hepatobiliary intervention or trauma. Hemobilia in the setting of cystic artery pseudoaneurysm secondary to type I Mirizzi syndrome is a rare occurrence. We report the case of a 61-year-old male who presented with epigastric pain and vomiting. Blood tests demonstrated hyperbilirubinemia with elevated inflammatory markers. Magnetic resonance cholangiopancreatography revealed type I Mirizzi syndrome in the presence of a 21 mm cystic duct stone. During endoscopic retrograde cholangiopancreatography, hemobilia was identified. Subsequent triple phase computed tomography imaging identified a 12 mm cystic artery pseudoaneurysm. Angiography with successful coiling of the cystic artery was accomplished. Cholecystectomy was performed, confirming type I Mirizzi syndrome. This case demonstrates the importance of considering ruptured pseudoaneurysm in patients presenting with evidence of upper gastrointestinal bleeding in the setting of biliary stone disease. Transarterial embolization, followed by surgical management, is effective in both the diagnosis and management of ruptured cystic artery pseudoaneurysm with associated hemobilia.

Acute hemorrhagic cholecystitis as a rare cause of hemobilia.

Hemobilia is an unusual type of gastrointestinal bleeding most frequently due to iatrogenic injury, trauma, or neoplasia. Acute cholecystitis as a cause of hemobilia is rare. We present the case study of a patient with bleeding from eroded gallbladder mucosa in the setting of severe calculous cholecystitis. The hemorrhagic episode was preceded by acute ERCP due to obstructive icterus with extraction of the calculi, followed by the development of severe acute pancreatitis. These factors initially misled the diagnosis. The bleeding was not hemodynamically important and routine diagnostic methods did not reveal its exact source. Direct choledochoscopy (SpyGlassTM) proved to be helpful in determining the right diagnosis, as it ruled out any injury or tumor in the main bile ducts and considerably supported the assumption of intrabladder bleeding. Surgical revision confirmed the cause, and subsequent cholecystectomy solved the whole problem.

[A Case of Hepatocellular Carcinoma with Haemobilia after Transcatheter Hepatic Arterial Embolization for Tumor Rupture].

A 79-year-old man was scheduled for surgery for hepatocellular carcinoma(HCC)after transcatheter hepatic arterial embolization for rupture. Two weeks before surgery, the patient came to our hospital with a chief complaint of back pain. First, we performed biliary drainage, under the diagnosis of HCC with obstructive jaundice due to haemobilia. Hepatectomy was performed when the patient's condition stabilized. It should be kept in mind that haemobilia may occur after TAE for HCC with bile duct tumor thrombus, and appropriate treatment should be performed when bleeding occurs.

A Bayesian Network Meta-Analysis Comparing Biliary Stent Types' Outcome and Complications in Unresectable Malignant Biliary Obstructions.

OBJECTIVE: To conduct a network meta-analysis (NMA) in comparing biliary stents types' outcomes and complications in unresectable MBO. METHODS: The study was conducted in accordance with the PRISMA and NMA extension . Comprehensive searches of the Cochrane Library, MEDLINE, and Scopus were done analyzing randomized controlled trials that included subjects with unresectable malignant biliary obstructions that underwent biliary stents placement from any approaches. The types of stents that included were full-covered metal (FMS), partially-covered metal (PMS), uncovered metal (UMS), plastic (PLS), Iodine-125 seeds strands (IRS), antireflux (ARS), and paclitaxel-coated (PXS) stents. The outcome parameters were clinical success, median patency duration, medial survival, and early 30-day mortality. The complications included were stent occlusion, stent migration, cholangitis, cholecystitis, pancreatitis, hemorrhage, and hemobilia. The NMA will be done based on Bayesian method, Markov Chain Monte Carlo algorithm, using BUGSnet package in R studio. Transivity was controlled by methods and consistency of the NMA will be fitted by deviance information criterion. Data analysis in NMA were presented in Sucra plot, league table, and forest plot. RESULT: Thirty-six RCTs were included with 3502 subjects. ARS had the best clinical success and longest median patency. However, it was associated with higher rate of  complications. IRS had a good clinical success (RR 1.63; 95%CI 0.67-6.25), long median patency (MD 21.14; 95%CI -106.18 to 145.91), and high significant survival rate (MD 69.89; 95%CI 22 to 117.57) compared to others stents. It was associated unsignificant complications of cholecystitis, hemobilia, and hemorrhage. CONCLUSION: Iodine-125 seeds strands had the promising good outcome and tolerated complications among others and should be considered as a standard stent to be used in unresectable malignant biliary obstructions.

Delayed Post-Traumatic Hemobilia in a Patient With Blunt Abdominal Trauma: A Case Report and Review of the Literature.

Hemobilia is a rare condition defined as bleeding in the biliary tract. The clinical presentation is variable. The typical manifestation consists of jaundice, upper gastrointestinal bleeding, and right upper quadrant abdominal pain. This set of symptoms is known as "Quincke's triad." It is present in only 22%-35% of cases. Post-traumatic hemobilia is an extraordinarily rare condition occurring in only 6% of the patients with hemobilia. In general, it occurs in less than 0.2% of patients with liver trauma. A delay in the development of bleeding after liver trauma is frequent. Early diagnosis is essential because massive bleeding into the biliary tract is a potentially life-threatening condition. We present a case of a patient with massive hemobilia developed 12 days after blunt abdominal trauma. Computed tomography angiography showed two pseudoaneurysms in hepatic segments V and VIII with contrast medium extravasation. We successfully performed digital subtraction angiography with selective transcatheter arterial embolization of the leaking segment VIII pseudoaneurysm. Embolization of the pseudoaneurysm in segment V was technically impracticable. Our article provides a review of the published literature focussing on the prevalence, diagnostics, and treatment of post-traumatic hemobilia.

Intratumoral Air Bubbles and Hematemesis As Predictors of Pseudoaneurysm Rupture in Unresected Pancreatic Cancer.

Objective Pseudoaneurysm rupture associated with unresected pancreatic cancer can cause rare but fatal hemobilia and gastrointestinal bleeding. This study aimed to identify factors predicting pseudoaneurysm rupture. Methods We conducted a single-center case-control study of unresected pancreatic cancer patients treated at Shizuoka General Hospital between January 2011 and July 2020 using a retrospective cancer registry database. Included in the study were 611 consecutive patients with unresected pancreatic cancer, of whom 55 developed overt upper gastrointestinal bleeding or hemobilia. Twenty patients were excluded, as they had not undergone contrast-enhanced computed tomography (CT) or angiography. Patients were classified into pseudoaneurysm and non-pseudoaneurysm groups. One patient with arterial bleeding but without obvious pseudoaneurysm was included in the pseudoaneurysm group. Factors predicting pseudoaneurysm rupture at the onset of overt gastrointestinal bleeding were investigated using a logistic regression analysis. CT findings revealing air bubbles inside the tumor were described as intratumoral air bubbles. Results Thirty-five patients were included (15 in the pseudoaneurysm group, 20 in the non-pseudoaneurysm group). In the multivariate analysis, intratumoral air bubbles [odds ratio (OR), 12.9; 95% confidence interval (CI), 2.14-77.9; p=0.005] and hematemesis (OR, 6.30; 95% CI, 1.03-38.6; p=0.047) were independent predictors of pseudoaneurysm rupture. In addition, patients who experienced successful hemostasis and were re-administered chemotherapy survived more than six months. Conclusion This study reveals that intratumoral air bubbles and hematemesis may predict pseudoaneurysm rupture at the onset of overt gastrointestinal bleeding. For patients presenting these findings, an examination with conventional or CT angiography may lead to an early diagnosis and improve the patient prognosis.

[Hemobilia due to ruptured superior pancreaticoduodenal pseudoaneurysm after chemoradiotherapy for pancreatic head cancer: an autopsy case report].

A 78-year-old man came to our department because of obstructive jaundice, and was diagnosed as pancreatic head cancer. He underwent chemoradiation therapy. A metal stent was inserted into the common bile duct and the patient was followed up on an outpatient basis. The patient visited our emergency department 46 days after stent insertion due to abdominal pain. The patient was diagnosed with ruptured pseudoaneurysm of the superior pancreaticoduodenal artery by angiography and treated with coil embolization. He died due to sudden deterioration the next day. Pathological autopsy revealed that the cause of the ruptured pseudoaneurysm appeared to be vasculopathy due to radiation therapy.

Rapid identification of source of delayed hemobilia following endoscopic metallic stenting for malignant biliary obstruction.

Delayed hemobilia, a rare but potentially fatal complication of endoscopic metallic stenting for malignant biliary obstruction, requires prompt identification of the source of bleeding and subsequent embolization. However, hemobilia is characteristically intermittent, and computed tomography (CT) often fails to show pseudoaneurysms or extravasations. In particular, because the posterior superior pancreaticoduodenal artery (PSPDA) runs alongside the common bile duct for its whole length, it is readily obscured by metallic artifacts in that duct, such as stents, making identification of the source of bleeding by CT difficult. We have encountered three patients with delayed hemobilia from the PSPDA following endoscopic biliary stenting for malignant biliary obstruction in whom no extravasation or pseudoaneurysms were detected by contrast-enhanced CT during bleeding. However, when we identified that the PSPDA had a smaller diameter than in previous CTs in all three cases, we suspected that the PSPDA was the source of the bleeding. No extravasation or pseudoaneurysms were detected with celiac arteriography or superior mesenteric arteriography; however, extravasation and pseudoaneurysms were detected by direct PSPDA angiography. Hemostasis was achieved through embolization. Detecting a large decrease in the diameter of the PSPDA on contrast-enhanced CT during biliary bleeding may help to identify the source of that bleeding.