Arteriobiliary Fistula Research Articles

Endovascular management of a ruptured hepatic artery pseudoaneurysm after liver transplantation presenting as hemobilia

Vascular and biliary complications can still occur among liver transplants despite advances in surgical technique and immunosuppression. Rupture of a hepatic artery pseudoaneurysm is a rare but lethal complication after liver transplantation and often manifests as acute gastrointestinal bleeding. It occurs in < 3% of cases with an associated mortality as high as 50% especially if diagnosed late. A high index of suspicion may decrease consequent morbidities and potential graft loss. Infection and type of biliary anastomosis are commonly identified risk factors in the development of a pseudoaneurysm. Angiography usually identifies the location which is commonly at the site of anastomosis. Frequent management options include surgical revascularization requiring re-operation or endovascular intervention with the use of coils and stents. No consensus yet as to the standard treatment has been established. We present a case of a 40-year-old male having a ruptured hepatic artery pseudoaneurysm with an arteriobiliary fistula after performing a deceased donor liver transplant managed with endovascular placement of a stent. Patient remains asymptomatic with patent hepatic artery after 6 months of follow-up.

Delayed appearance of hepatic artery pseudoaneurysm and an arterio-biliary fistula secondary to biliary leakage and bilioma formation in a liver trauma patient and its management through transarterial embolization

BackgroundPseudoaneurysm and arterio-biliary fistulas are infrequent complications of surgery or iatrogenic trauma, accidental trauma, tumors, vascular malformations, infection, and inflammation of the biliary tract. In a liver trauma patient, they evolve immediately secondary to direct vascular injury and usually present with either drop in hemoglobin level or hemobilia due to bleeding into the peritoneal space or biliary system. In the present case, there were no clinical features of hemobilia or upper gastrointestinal bleeding. Moreover, the hepatic artery pseudoaneurysm and arterio-biliary fistula evolved after a latent period of a few weeks, secondary to the toxic effects of the bile on the vessel walls due to biloma formation or biliary leakage, which is exceptionally uncommon.Case presentationThis 19-year-old male presented with a severe liver injury complicated by forming a biloma, followed by the development of a pseudoaneurysm and an arterio-biliary fistula. The appropriate hepatic artery branch was successfully embolized using an endovascular approach.ConclusionsIn a liver trauma patient, the latency period for developing a pseudoaneurysm and an arterio-biliary fistula can be from a few days to a few months due to direct vascular injury or toxic effects of the bile on the adjacent vessel walls secondary to bile leakage. Development of hepatic artery pseudoaneurysm and an arterio-biliary fistula after a latent period of a few weeks, secondary to the toxic effects of the bile on the vessel walls due to biloma formation or biliary leakage, is exceptionally uncommon. So, these liver trauma patients require close monitoring and follow-up for early detection and treatment of pseudoaneurysm and arterio-biliary fistula, especially when there are clinical or imaging features of bile leakage or biloma formation. Endovascular treatment of hepatic artery pseudoaneurysm and arterio-biliary fistulas is a safe and effective method.

Clinical Impact and Safety of Non-Target Punctures (NTP) during Portal Vein Access in TIPS Procedure.

Although non-target puncture (NPT)-related complications are well known to clinicians performing TIPS, there is no NTP-focused study to assess the true clinical sequalae of NTP-related complications. In this study, the aim was to evaluate the incidence, safety, clinical outcomes and complications related to NTPs during the portal access of TIPS procedures. A retrospective review of 369 TIPS procedures from October 2007 to September 2019 was performed. We identified inadvertent NTPs, including biliary, hepatic artery, lymphatic and capsular punctures. Next, the medical records and images were reviewed and analyzed to assess the safety and clinical outcomes of these cohorts. A total of 71 NTPs were identified in 56 patients (15.18% of 369 patients). Of 369 TIPS patients, there were (1) 28 biliary punctures (7.6%), (2) 16 extracapsular punctures (4.3%), (3) 15 lymphatic punctures (4.1%) and (4) 12 hepatic artery punctures (3.3%). The overall complication rate was 2.2% (8/369). Based on the Clavien-Dindo classification, three patients (0.8%) had a minor complication. In addition, five patients (1.4%) experienced grade II-V major complications, such as symptomatic hemoperitoneum, arterio-biliary fistula or hemorrhagic shock leading to death. Mortality (0.5%) was only caused by extracapsular puncture combined with other NTP. NTPs during the portal access of TIPS procedures are associated with low complication risk. However, when extracapsular punctures are combined with other NTPs, a more severe complication, including mortality, can occur. Nevertheless, all patients with NTP should be closely monitored at a higher level of care after TIPS placement.

Hemobilia as a sign of arterio-biliary fistula

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.

Iatrogenic arterio-biliary fistula and peripheral hepatic artery pseudoaneurysm after transjugular liver biopsy: complication management using a microvascular plug

This study aimed to report on complication management in a 58-year-old woman referred for transjugular biopsy for the evaluation of unknown liver disease. After an initial uneventful biopsy procedure, the patient complained of severe upper abdominal pain. Laboratory tests revealed increasing liver enzymes. Imaging studies depicted an iatrogenic pseudoaneurysm associated with an arterio-biliary fistula originating from the right peripheral hepatic artery. Angiography and percutaneous transarterial superselective embolotherapy was performed by means of a microcatheter and microvascular plug. Precise device positioning allowed for successful closure of the bleeding site without compromising the hepatic vasculature.

Massive Hemobilia Due to Arteriobiliary Fistula after the Transjugular Intrahepatic Portosystemic Shunt (TIPS): A Case Report

The transjugular intrahepatic portosystemic shunt (TIPS) is an effective method for the treatment of uncontrolled refractory ascites, pleural effusion, and variceal bleeding, but the risk of complications related to the procedure is high. Arteriobiliary fistula, which is manifested as hemobilia, is one of the major fatal complications of the TIPS. Most of the TIPS-related bleeding is a complication that occurs mainly during the portal vein puncture. We are reporting a case of massive hemobilia due to hepatic arteriobiliary fistula caused by TIPS procedure.

Two distinct episodes of life-threatening hemobilia due to a lesion of common bile duct and delayed intrapancreatic arteriobiliary fistula managed by emergency pancreatoduodenal resection.

Hemobilia is an extremely rare cause of upper gastrointestinal bleeding. It often has intermittent manifestation, which may lead to significant diagnostic delay. In 65% of the cases, the causes are iatrogenic, in 7% the cause is malignancy, in 5% - gallstones, in 8% it is inflammation (cholecystitis, parasites, reflux cholangitis), vascular abnormality is the cause in 7% (most commonly pseudoaneurysm of the hepatic artery), and pancreatic pseudocyst causes hemobilia in 1%. In almost all cases, the bleeding originates from intrahepatic or extrahepatic bile ducts, and rarely from the pancreas.

Acute Arteriobiliary Fistula Emergent Long after Biliary Drainage and Radioembolization

AbstractVarious causes of hemobilia have been described in the literature, majority being iatrogenic. Other different pathologies such as inflammation and tumors also have been described. A 55-year-old male, who had a history of obstructive jaundice caused by a 4-cm liver mass treated with external-internal biliary drainage and transarterial radioembolization 6 months back, presented with acute hemobilia. Computed tomography demonstrated widespread radionecrosis of the right lobe and extravasation of intravascular contrast from right hepatic artery into common bile duct. Verified on angiography, the arteriobiliary fistula was managed with coil embolization.

A Case Report: Hepatic artery pseudoaneurysm causing life-threatening haemobilia.

Introduction & importanceHepatic artery aneurysms (HAA) are rare and it accounts 20% of all visceral artery aneurysms. Commonly HAAs are autopsy findings, but rupture and bleeding carrying significant morbidity and can manifest as haemobilia.Case presentationA 63-year-old Sri Lankan male presented with severe melaena upper abdominal pain and features of obstructive jaundice was found to have a giant pseudoaneurysm at the right hepatic artery with the possible arterio-biliary fistula. The etiology for the pseudoaneurysm was not identified. Despite massive transfusion, the patient died before the endovascular intervention.Clinical discussionAtherosclerosis is the leading cause of HAA formation but can be associated with connective tissue disorders and arteritis. Most of the HAA are asymptomatic. Aneurysms can be managed with surgical or endovascular interventions.ConclusionLife-threatening haemobilia is a notorious complication of the rapture of HAA into the biliary system. The incidents of hepatic artery aneurysms and pseudoaneurysms due to percutaneous transhepatic interventions and minimal invasive hepatobiliary surgeries are in the rising trend. Nonleaking VAA can be best treated with endovascular treatment. The knowledge on this topic is important for the early detection and intervention of this rare entity.

Arterio-biliary fistula caused by a hepatic artery pseudoaneurysm in a recently performed liver transplant: successful resolution and long-term liver implant preservation using a covered coronary stent

BackgroundThe formation of a hepatic artery pseudoaneurysm in a liver implant is a rare but potentially fatal complication. Fistulization of such pseudoaneurysms into the bile duct is sporadic. The most common causes of hepatic artery pseudoaneurysm are infection at the anastomosis site, inadequate surgical technique, and an iatrogenic origin due to minimally invasive procedures. Currently, there is no standardized treatment in neither of these complications, with surgery and various endovascular procedures among the alternatives available. None of these therapeutic approaches has demonstrated a significant increase in long-term liver implant preservation.Case presentationA 56-year-old man with a two-month liver transplant presented with massive upper gastrointestinal bleeding and hemobilia shortly after the performance of an endoscopic retrograde cholangiopancreatography due to the presence of a hepatic artery pseudoaneurysm with fistulization into the bile duct. This case report describes the successful treatment of both complications, the hepatic artery pseudoaneurysm and the arterio-biliary fistula, using a covered coronary stent placed in the hepatic artery. A year and a half after treatment, the patient maintains a preserved liver implant and a patent hepatic artery.ConclusionsTreatment of a hepatic artery pseudoaneurysm with fistulization into bile duct using a covered coronary stent allowed the correct repair of the defect, adequate hemorrhage control, and long-term liver implant preservation.

S1513 Liver Biopsy Leading to Hemobilia Complicated by Cholangitis, Biliary Pancreatitis, and Massive Gastrointestinal Hemorrhage

INTRODUCTION: Percutaneous liver biopsies (PLB) are performed routinely to investigate liver masses, unexplained hepatomegaly or abnormal liver chemistries and are relatively safe in the absence of coagulopathy. Here, we present a rare complication of PLB: arterio-biliary fistula presenting with delayed onset of hemobilia, massive gastrointestinal hemorrhage, acute cholangitis and acute biliary pancreatitis requiring emergent embolization and antimicrobial therapy. CASE DESCRIPTION/METHODS: A 62-year-old female recently diagnosed primary biliary cholangitis presented with hematemesis, hematochezia and jaundice 1 week after percutaneous liver biopsy. On admission, she was febrile, hypotensive and tachycardic. Physical exam was notable for scleral icterus, jaundice and right upper quadrant abdominal tenderness with voluntary guarding. Rectal exam revealed a large amount of bright red blood. Laboratory data was significant for hemoglobin of 7.7 g/dL from 11.1 g/dL prior to liver biopsy, total bilirubin 7.5 mg/dL (1.0 unconjugated/4.5 conjugated), ALP 587 U/L, GGT 504 U/L, AST 98 U/L, ALT 83 U/L, lipase 3017 U/L. CT angiography of the abdomen showed contrast throughout the proximal hepatic and common bile ducts concerning for active bleeding from an arterio-biliary fistula resulting in hemobilia, moderate biliary dilation, and bowel contents concerning for intraluminal bleeding from the biliary system. She was treated with broad-spectrum antibiotics and successfully resuscitated with IV crystalloids and blood products. She underwent emergent mesenteric angiography with left hepatic artery and arterioportal fistula coil embolization which resulted in hemostasis and rapid normalization of liver chemistries. DISCUSSION: Major gastrointestinal bleeding complications due to iatrogenic arterio-biliary fistula formation after PLB are exceedingly rare, occurring less than 1% of the time due to needle intersection with the portal triad, resulting in epithelialized shunt formation between the hepatic artery and bile duct. This case represents a later presentation of hemobilia, which typically occurs within 24 hours of PLB. The accumulation of blood clots in the biliary tree can lead to life threatening cholangitis and biliary pancreatitis. Early recognition of this complication is essential as urgent embolization and aggressive antimicrobial therapy can lead to a significant reduction in mortality.Figure 1.: CT angiogram abdomen/pelvis: contrast visible in the common hepatic duct.Figure 2.: Pre-embolization: segment 3 branch of hepatic artery.Figure 3.: Post-embolization: segment 3 branch of hepatic artery.

Robotic Repair of a Right Hepatic Artery-to-Common Hepatic Duct Fistula Status Post-Endoscopic Retrograde Cholangiopancreatography

Background: Arteriobiliary fistula is a rare pathology and is often attributable to iatrogenic causes. Acute presentation is common because of shunting of high-pressure blood from the hepatic arter...

Hemobilia in percutaneous transhepatic cholangiostomy

Aim. To determine the dependence of the formation of vascular-biliary fistula with the bile ducts bleeding and along the drainage channel on the diameter of the puncture needle and access to the biliary tract.Materials and methods. A retrospective analysis of the results of treatment of 3786 cases of percutaneous transhepatic cholangiostomy using needles 17.5-18 G under Amplatz 0.035’ conductor with a safe J-tip was carried out. In the cholangiostomy in the bile ducts was installed biliary tree drainage shape memory No 8 Fr. In benign lesions of the bile ducts 2066 (54.6%) interventions were performed, 1720 (45.4%) for malignant ones. Central access to the bile ducts was performed in 2442 cases (64.5%), peripheral – in 1344 cases (35.5%).Results. Significant hemobilia was observed in 21 (0.55%) cases: in 8 (0.47%) with a obstructive jaundice of malignant etiology, in 13 (0.63%) – benign etiology. In 3 cases, the cause of hemobilia was arteriobiliary fistula, in 16 – portobiliary, in 2 – biliovenous fistula. Central access was complicated by significant hemobilia in 10 patients, peripheral – in 11.Conclusion. The low frequency of significant hemobilia – 0.55% – when using puncture needles 17.5–18 G for primary access to the bile ducts proves the validity of their use in radiological practice, and also does not allow to consider central access critical for the development of hemorrhagic complications in percutaneous transhepatic biliary drainage.

Interventional Radiological Treatment of Paediatric Liver Transplantation Complications.

To assess the efficacy of percutaneous techniques in managing paediatric liver transplantation complications. We carried out 105 paediatric cadaveric donor liver transplantations at our centre from 2001 to 2018. Percutaneous techniques were used to treat 25 cases involving transplantation complications in 23 patients. Biliary complications were treated in 14 cases (13.3%): 10 patients had bile duct obstruction, and 4 had biliary leaks. Vascular complications were treated in 11 cases (10.5%): 5 hepatic artery (HA) stenoses/occlusions, 2 inferior vena cava (IVC) stenoses, and 1 portal vein (PV) stenosis. Other interventions involved embolisation of the superior mesenteric artery branch to manage gastrointestinal bleeding in 2 patients and embolisation of an arteriobiliary fistula in 1 patient. Biliary: We carried out external-internal drainage and balloon dilatation of stenoses in 12 cases. The external-internal drainage catheter was removed after 6-8weeks in 7 patients, with the remaining 5 patients with persisting stenosis assigned for retransplantation. We failed to cross anastomotic occlusions in 2 patients before completing the procedures using external drainage; both individuals subsequently underwent retransplantation. Vascular: We performed PTA/stenting of HA stenoses/occlusions in 4 out of 5 patients. After the procedure, all 4 patients showed liver function normalisation. All 3 cases of embolisation were technically and clinically successful. Both IVC and PV stenoses treated with dilatation/stenting were also successful. Percutaneous techniques used to treat biliary and vascular complications after liver transplantation in paediatric patients are safe and efficient.

Fístula portobiliar como complicación mayor de biopsia hepática transpercutánea bajo marcación ecográfica

Woman of 71 years, in study of chronic liver disease, Child-Pugh A, computed tomography (CT) suggestive of cirrhosis, autoimmune hepatitis score probable. It was decided to perform a liver percutaneous biopsy for diagnosis and treatment. After the procedure, the patient presented a self-limited episode of hematemesis. Upper digestive endoscopy without blood or other injury, abdominal ultrasound without free liquid. The patient was hospitalized, evolving hemodynamically stable without new bleeding episodes. Medical discharge was decided after 24 hours of observation. The patient consults the next day at emergency room because of intense abdominal pain and anemia. CT Impressed a dilated bile duct with hyperdense content inside, so she was rehospitalized. The patient evolved with melaena and hypotension. Biliary hematoma due to arteriobiliary fistula was suspected. CT angiogram evidenced portobiliary fistula. It was managed with endovascular therapy but the patient remained hypotense with a requirement for vasoactive drugs and multi-organ dysfunction, and she finally died.

Transcatheter arterial embolization for gastrointestinal bleeding related to pancreatic adenocarcinoma: clinical efficacy and predictors of clinical outcome

PurposeTo evaluate the clinical efficacy of transcatheter arterial embolization (TAE) for managing pancreatic adenocarcinoma-related gastrointestinal (GI) bleeding, and to determine the factors associated with clinical outcomes. MethodFrom 2001–2017, this retrospective study included 58 patients who underwent TAE for pancreatic adenocarcinoma-related GI bleeding. The technical and clinical success of TAE, clinical factors including patient characteristics and embolization details, complications, and the 30-day mortality were evaluated. Univariate analyses were performed to determine the factors related to the clinical outcomes. ResultsOn angiography, bleeding foci were detected in 47 patients (81%), while the other 11 patients showed tumor staining. Technical success rate was 98%, and first session and overall clinical success rates were 79% and 88%, respectively. N-butyl cyanoacrylate (NBCA) was the most commonly used embolic agent (53%). Stent-related bleeding was shown in 22 patients with characteristic angiogram such as arterial cut-off (13/22) and arteriobiliary fistula (5/22), with comparable clinical success rate (82%). Bleeding from the superior mesenteric artery (n = 3) at the first session of angiography and complications (n = 2), such as ischemic hepatitis and small bowel infarction, were all associated with a 30-day mortality. The overall 30-day mortality rate was 22%. Univariate analysis showed that massive transfusion and TNM stage 4 were related to clinical failure (P = 0.035 and 0.038, respectively). ConclusionsTAE was effective and safe for pancreatic adenocarcinoma-related GI bleeding. Stent-related bleeding was not uncommon, and associated with vascular abnormality amenable to TAE. Massive transfusion and TNM stage 4 were related to clinical failure.

Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction.

To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO). From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52-82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE. The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22-2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein. TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO. This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.

1271 Arteriobiliary Fistula Repair With Biliary Endoprosthesis: When Trans Arterial Embolization Is Not an Option

INTRODUCTION: Arteriobiliary fistula is an uncommon complication manifesting as hemobilia or an upper gastrointestinal (GI) bleed. Etiologies include intra-hepatic artery chemo-embolization, trauma or previous invasive biliary instrumentation. We describe a case report of using two fully covered metal biliary stents for closure of an acquired arteriobiliary fistula. CASE DESCRIPTION/METHODS: 20-year-old male with history of neuroblastoma s/p resection and chemoradiation underwent placement of percutaneous transhepatic biliary drain (PTBD) for common bile duct (CBD) strictures. He was admitted to the hospital with acute blood loss anemia, transaminitis and sanguineous output from the biliary drain. Upper endoscopy revealed one clean based gastric ulcer which was injected with epinephrine. Patient was scheduled to undergo replacement of external/internal biliary drain. Intraoperative cholangiogram revealed extensive thrombus within central biliary ducts. It also demonstrated a fistulous connection between the common hepatic duct and the right hepatic artery. Angiogram showed replaced right hepatic artery, originating from superior mesenteric artery with occluded 4 cm proximal end, distal reconstitution was seen via fine collaterals; which made endovascular repair impossible (Figure 1 left). As a temporizing measure, a COOK 16 Fr × 40 cm biliary drain was replaced and advanced beyond the arterial-biliary fistulous connection, serving as a tamponade (Figure 1 right). Over the subsequent days, patient continued to have intermittent sanguineous biliary output. After surgical options were ruled out, two GORE VIABAHN 11 mm × 29 mm balloon expandable fully covered metal stents were deployed within the common bile duct to exclude the biliary-right hepatic artery fistula (Figure 2 left, right). A similar sized biliary drain was replaced subsequently (Figure 3). Hemobilia resolved and hemoglobin remained stable. Patient was discharged successfully to a center of excellence for multivisceral transplant. DISCUSSION: The management of hematobilia often includes an initial cholangiogram, if an arterial source is identified, hepatic artery embolization is the treatment of choice. This unique case demonstrates the utility of an endobiliary prosthesis for exclusion of arteriobiliary fistula where endovascular repair was not an option. The shortest possible endoprosthesis should be used to avoid obliteration of other large vessels or bile duct branches. Complications include bacteremia and liver infarction adjacent to stent-grafts.

Hemobilia: an unusual and life threatening complication of laparoscopic cholecystectomy

Hemobilia though rare, occurs due to abnormal vascular and biliary communication established as a result of trauma, gallstones, neoplasms, inflammatory process and vascular disorders. It can rarely complicate a laparoscopic cholecystectomy as a result of hepatic artery injury, clip migration, clip erosion, diathermy and subsequent arteriobiliary fistula, or pseudoaneurysm eroding into the extra hepatic bile ducts. A 34 years female underwent laparoscopic cholecystectomy for cholelithiasis, suffered bile leak that settled on by 13th postoperative day, met with sudden right upper abdominal pain and hypovolemic shock on 15th postoperative day due to massive hemobilia arising out of rupture of pseudoaneurysm of the right hepatic artery into the biliary system. Urgent CT Angiography showed a large pseudoaneurysm of right hepatic artery branch with adjacent small collection, IHBR and CBD dilatation suggestive of hemobilia. Emergency CT guided trans-arterial hepatic artery embolization done to control hemobilia and save the patient. An immediate CT angiography for early diagnosis, in all postoperative laparoscopic cholecystectomy cases with suspicion of hemobilia due to an underlying hepatic artery pseudoaneurysm, followed by CT guided trans-arterial hepatic artery embolization forms the gold standard management in such patients.

Trans biliary proximal and distal coil embolization of an arteriobiliary fistula: report of a case and review of literature

BackgroundHepatic arterial injury is an uncommon complication of percutaneous transhepatic biliary drainage interventions that commonly presents with hemobilia and peri catheter hemorrhage. It is classically managed with antegrade trans arterial embolization. However, this approach may not be possible due to altered anatomy and alternative techniques need to be considered. We report a case of an arteriobiliary fistula which was successfully coil embolized both distal and proximal to the lesion using a trans biliary approach. This is the first report of such method and interventionalists should be aware of this option. The literature is reviewed.Case presentationWe report a case of a 49-year-old male with advanced colorectal cancer presented with cholangitis. His duodenal anatomy precludes endoscopic intervention, so he underwent percutaneous biliary drainage complicated by intractable hemobilia and pericatheter bleeding. Hepatic arterial anatomy evaluated by two catheter angiographies was shown to be isolated at multiple levels by tumors and prohibited antegrade access of bleeding artery for embolization. Sheath cholangiography revealed an arteriobiliary fistula involving left hepatic arterial branches. The arterial injury was successfully treated by coil embolization distal and proximal to the lesion via a retrograde trans biliary approach, with complete resolution of hemobilia.ConclusionTrans biliary proximal and distal coil embolization is a newly reported approach for treating biliary hemorrhage when traditional antegrade arterial embolization is not feasible due to preclusive anatomic factors. Interventionalists should be familiar with this management option.