S2555 Right Hepatic Artery Pseudoaneurysm: A Rare Complication of Biliary Stent Placement

Abstract

Introduction: Formation of pseudoaneurysm is a rare but serious adverse event of biliary stenting. We present a case of a patient who presented with massive upper gastrointestinal bleeding two months after biliary stent insertion. Angiography revealed a right hepatic artery pseudoaneurysm which was successfully treated with transcatheter arterial embolization. Because bleeding may be fatal, timely diagnosis of the condition is important. Case Description/Methods: A 65-year-old-man with a past medical history of recurrent gallstone pancreatitis underwent Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with sphincterotomy and fully covered metal stent placement was admitted to our hospital for severe hematemesis. Labs revealed a drop in hemoglobin from 7.6 to 5.8. After endotracheal intubation, activation of the massive transfusion protocol (MTP) Minnesota tube placement, emergent esophagogastroduodenoscopy (EGD) was performed at the bedside, which showed a large amount of clotted blood but no active bleed. The next day, again he developed severe upper gastrointestinal bleeding leading to hypovolemic shock. MTP was activated again, and a Minnesota tube reinserted. After intensive resuscitation, a computed tomography angiography (CTA) was performed which showed a 6 cm large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery. Successful embolization of the common hepatic artery was performed without complications. No recurrent bleeding occurred over the following days. Discussion: This case demonstrates a rare complication of biliary stents which was successfully treated with transcatheter arterial embolization. It is important to consider that a pseudoaneurysm is a potential adverse event caused by a biliary stent because timely diagnosis and treatment are required to prevent fatal hemorrhage and death.Figure 1.: A. Large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery and abuts the distal gastric antrum/proximal duodenum. B. Injection from celiac artery demonstrating a bilobed pseudoaneurysm originating from the common hepatic artery/proximal right hepatic artery at the level of the intersection with the biliary stent. C. Post IR embolization CTA showing common hepatic artery without opacification and previously seen pseudoaneurysm.