Acute Hemobilia After Bilioplasty Due to Hepatic Artery Pseudoaneurysm: Treatment with an ePTFE-Covered Stent

Abstract

A 61-year-old male underwent biliodigestive anastomosis (BDA) 7 years after orthotopic liver transplantation (OLT) due to intraand extrahepatic lithiasis. One month later he developed cholangitis and jaundice. Ultrasound examination revealed intrahepatic duct dilatation associated with the presence of stones. Percutaneous transhepatic cholangiography (PTC) and drainage were deemed necessary due to elevation of bilirubin levels and risk of sepsis. PTC revealed a stricture at the level of the previous BDA, with several filling defects in the common bile duct (CBD), which were attributed to the presence of stones. An 8-Fr internal/external drainage catheter (Flexima; Boston Scientific, Watertown, MA, USA) was initially used to decompress the biliary tree and gradually replaced with wider ones, up to 14 Fr, over the next 7 days. Lithotripsy was then decided on, and a 0.035-in. stiff guidewire (Amplatz; Boston Scientific Corp., Natick, MA, USA) was advanced into the drainage catheter. Upon advancement of the wire into the catheter it accidentally came out of one of the side holes into the liver parenchyma, and when the catheter was removed a jet of massive highpressure hemorrhage followed from the catheter tract. A new 14-Fr catheter was immediately inserted into the hepatic tract and angiography followed, but without the necessity for further intervention. The patient remained stable for the next 48 h and reintervention was decided on. Dilatation of the BDA was performed with a 10 9 20-mm balloon and stones were advanced toward the bowel loop with a biliary extraction balloon. Two days later cholangiography was repeated and the external catheter was removed by a new high-pressure hemorrhage episode from the catheter tract. The patient became hemodynamically unstable, angiography was repeated, and a small, saccular aneurysm was demonstrated at the right hepatic artery main branch, close to the bilioplasty region (Fig. 1). A 3.5 9 16-mm balloon-expandable coronary stentgraft (Graftmaster Jostent; Abbott Vascular, Ulestraten, Holland), covered eith expandable polytetrafluoroethylene (ePTFE), was advanced over a 0.014-in. stiff wire toward the aneurysm. Although the common hepatic artery had a stenosis, the stent was successfully advanced and deployed,