Hepatic Artery Pseudoaneurysm Eroding into Common Bile Duct in a Liver Transplant Recipient

Abstract

Hepatic artery pseudoaneurysm is an uncommon but serious complication that can occur after liver transplantation. Overall incidence is estimated to be around 2% but risk factors remain poorly defined. We present the case of a patient who presented with hemobilia due to hepatic artery pseudoaneurysm eroding into the bile duct within a few weeks of liver transplantation. The patient is a 65 year old male who underwent orthotopic liver transplantation (LT) for Hepatitis C cirrhosis and hepatocellular carcinoma. Post-transplant immunosuppression consisted of tacrolimus and mycophenolate mofetil. Medical co-morbidities included hypertension and type 2 diabetes. Duplex Ultrasonogram in immediate post-transplant period revealed mild parvus et tardus hepatic artery waveforms that remained stable. One week post-LT, patient underwent endoscopic retrograde cholangiopancreatography (ERCP) for evaluation of abnormal liver tests (aspartate aminotransferase (AST) 294 IU/L, alanine aminotransferase (ALT) 263 IU/L, Alkaline phosphatase 757 IU/L, total bilirubin 2.4 mg/dl, direct bilirubin 1.4 mg/dl). A tight anastomotic stricture was found, and biliary sphincterotomy was performed with placement of 2 biliary stents. Post-procedural course was complicated by mild pancreatitis, which resolved with conservative measures. Liver enzymes remained persistently elevated, and a percutaneous liver biopsy was performed 2 weeks after ERCP. Histologic findings were consistent with large duct obstruction. A week later, patient presented with abdominal pain and hematochezia. Computed tomographic angiogram was suggestive of hepatic artery pseudoaneurysm as well as occlusion of right portal vein. Repeat ERCP was performed that showed hemobilia and a pseudoaneurysm with hepatic artery to common bile duct fistula. The patient underwent surgical resection of pseudoaneurysm and bile duct, hepaticojejunostomy and revascularization of hepatic artery. Patient is alive and doing well after a 2 week follow up. Extension of a pseudoaneurysm into the common bile duct is a rare but potentially fatal complication. Although surgical technique is the most cited etiology for hepatic artery complications, percutaneous liver biopsy might have contributed in our case. This case demonstrates the criticality of early detection and appropriate management.