Delayed Formation and Rupture of a Pseudoaneurysm After Transjugular Liver Biopsy in a Pediatric Bone Marrow Transplant Patient: Imaging and Endovascular Treatment

Abstract

Dear Editor: A 7-year-old girl with relapsed pre–B cell acute lymphoblastic leukemia was referred for liver biopsy for abnormal liver function (high alanine aminotransferase, aspartate aminotransferase, and bilirubin values) 2 months after a second bone marrow transplantation (BMT). In the weeks preceding the liver biopsy, she had developed feeding intolerance, vomiting, diarrhea, and pneumatosis intestinalis. Endoscopic biopsies confirmed graft versus host disease (GVHD) in the stomach, duodenum, colon, and rectum. The differential diagnosis for the liver dysfunction included GVHD and total parenteral nutrition cholestasis. On the evening before she underwent liver biopsy, her laboratory values were as follows: hemoglobin 12.3 g/dL, hematocrit 35.7%, white blood cell count 7,810/lL, platelets 41,000/lL, prothrombin time 11.9 s, international normalized ratio of prothrombin time 1.13, partial thromboplastin time 27.6 s, and fibrinogen 296 mg/dL. Given her moderate thrombocytopenia, she received platelet transfusions, and the decision was made to perform the biopsy via a transjugular approach. On the morning of the procedure, her platelet count was 101,000/lL. The right internal jugular vein was accessed by ultrasound guidance and micropuncture technique, and an 8.5French vascular sheath was placed. Through this sheath, the 7-French LABS 200 sheath (Cook Bloomington, IN) was introduced into the right hepatic vein, and five passes were made with the 19-gauge cutting cannula under fluoroscopic and sonographic guidance. Multiple passes were necessary because several of the cores were fragmented. Postbiopsy venography and ultrasound were normal (Fig. 1). An ultrasound performed for abdominal pain 5 h after the biopsy demonstrated trace perihepatic fluid and unchanged free fluid in the pelvis. The hematocrit level remained stable. On postoperative day 5, a computed tomographic (CT) scan of the abdomen and pelvis with contrast performed for chest pain demonstrated a normal liver with free fluid in the pelvis (Fig. 2A). On postoperative day 8, an abdominal ultrasound performed for right upper quadrant pain showed a small amount of free fluid in the pelvis. On postoperative day 13, her hematocrit dropped 8 points in a 24-h period to 19.6%, and she developed abdominal distention. Urgent enhanced CT and ultrasound scans demonstrated a large liver hematoma around an actively filling pseudoaneurysm. Increased echogenic fluid in the pelvis was also noted, indicating rupture of the pseudoaneurysm into the peritoneal cavity (Fig. 2B, C). The patient was taken emergently to the angiography suite. Under general anesthesia, selective angiography of the hepatic artery with a 0.038-inch 4-Fr vertebral catheter demonstrated rapid filling of a large pseudoaneurysm fed by the right hepatic artery branch to segment VI (Fig. 3A, B). Access to the feeding vessel was obtained with a coaxial Prowler 14 microcatheter (Cordis Miami, FL). The tip of the microcatheter was gently advanced into the ‘‘neck’’ of the pseudoaneurysm, and embolization was carried out with 67% n-butyl cyanoacrylate glue opacified with Ethiodol. Care was taken to embolize the feeding vessel proximal and distal to the neck as well as the neck B. J. Dillon A. I. Alomari (&) Department of Radiology, Division of Vascular and Interventional Radiology, The Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA e-mail: ahmad.alomari@childrens.harvard.edu