Guglielmi Detachable Coil Erosion into the Common Bile Duct after Embolization of Iatrogenic Hepatic Artery Pseudoaneurysm

doi:10.1016/S1051-0443(07)61778-3

Journal of Vascular and Interventional Radiology

Volume 13, Issue 9, Part 1, September 2002, Pages 935-938

https://doi.org/10.1016/S1051-0443(07)61778-3 Get rights and content

Intermittent hemobilia with a hepatic artery pseudoaneurysm can be seen after open or laparoscopic cholecystectomy. Transcatheter treatment of this complication is widely accepted. Although some authors suggest packing the pseudoaneurysm with coils as the treatment of choice, occluding the parent artery is the standard treatment. The authors present an unusual complication of Guglielmi detachable coil erosion into the common bile duct in a patient who presented with pancreatitis 2 years after undergoing packing of the hepatic artery pseudoaneurysm with coils. The probable causes of this rare outcome and alternative treatment options are discussed.

Section snippets

CASE REPORT

A 58-year-old man underwent cholecystectomy for acute cholecystitis. During surgery, the surgeons had difficulty dissecting the cystic duct and artery and the gallbladder was subsequently amputated proximal to the cystic duct and artery. Hemostasis was achieved with use of Bovie electrocautery. The distal amputated portion of the gallbladder was oversewn with 3–0 silk suture. Two drains were placed in the subhepatic space. The postoperative period was unremarkable except for a single febrile

DISCUSSION

Although more rarely encountered than biliary complications, vascular complications after open or laparoscopic cholecystectomy can occur, especially in the presence of anatomy that is either abnormal or difficult to define (1, 2, 5, 6, 7, 8). Hepatic artery pseudoaneurysm, which is more common after trauma or percutaneous biliary interventions, occurs with an incidence of 0.5%– 0.8% after laparoscopic cholecystectomy. Mechanism of injury is usually direct trauma or diathermy shorting on

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Several studies have demonstrated that metallic devices implanted into internal organs or against mucosal surfaces can erode through soft tissue in both humans [24] and animal models [25,26]. In particular, many case reports have documented metallic coils eroding through various soft tissue structures, including the gastrointestinal tract [27,28], kidneys [29], esophagus [20], and pelvic structures [30]. In rare cases, coil embolotherapy in the pulmonary system can pose a risk for intrabronchial coil erosion and migration, which can occur years after the embolization procedure.
Pulmonary arteriovenous malformations develop in approximately 50% of hereditary hemorrhagic telangiectasia patients. Pulmonary arteriovenous malformations are often treated with coil embolization therapy. We report a case of a 45-year-old female with multiple pulmonary arteriovenous malformations due to underlying hereditary hemorrhagic telangiectasia who had undergone 14 coil embolization procedures over 16 years. She presented with sudden onset severe, unremitting, nonproductive cough from a foreign body sensation in the airway. Computed tomography of the chest demonstrated a metallic foreign body extending from the left lower lobe of the lung into the left mainstem bronchus and trachea. Bronchoscopy-guided removal of the foreign body revealed an intact embolization coil placed 8 years prior to presentation had partially migrated through the vessel and airway walls into the airway lumen, extending from the left lower lobe bronchus to the left mainstem bronchus. Coil migration is a rare, but potentially dangerous, complication of coil embolization therapy.
Migrated embolization coil causes intestinal obstruction
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The PubMed database was searched for all English reports of coil migration, and the bibliography of each publication was further evaluated for any additional cases. Five cases of coil migration from a hepatic artery pseudoaneurysm to the bile duct occurring 3 months to 8 years after the procedure (average of 29 months) have been reported.8-12 Four cases of coil migration from the carotid circulation have been reported.13-16
Visceral artery pseudoaneurysm is a rare, potentially fatal entity, but proper identification and management with coil embolization can lead to good outcomes. Embolization coils can migrate to various destinations, causing delayed complications in several case reports. A case of small bowel obstruction due to migrated embolization coils from a gastroduodenal pseudoaneurysm 6 years after initial treatment is presented.
“Coildocholithiasis”—Common Bile Duct Obstruction Secondary to Migration of Right Hepatic Artery Pseudoaneurysm Coils
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Successful treatment of an iatrogenic right hepatic artery pseudoaneurysm and stenosis with a stent graft
2010, Journal of Vascular Surgery
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The collateral circulation is not always sufficient, however, and hepatic infarction and necrosis have been reported as a complication of hepatic artery embolization.10-12 Other complications include recanalization of the vessel, requiring repeat embolization or surgical intervention, migration of coils,6,12 and coil erosion into the common bile duct.13 The alternative approach of embolization of the pseudoaneurysm cavity itself has the advantage of maintaining blood flow through the hepatic artery but is more technically challenging and can result in incomplete ablation of the pseudoaneurysm or occlusion of the hepatic artery.
A 53-year-old woman presented with an iatrogenic right hepatic artery pseudoaneurysm after a laparoscopic cholecystectomy. Approximately 1 year after the cholecystectomy, liver transaminases were elevated, and she complained of recurrent “crampy” right upper quadrant pain that radiated posteriorly to her back. Imaging studies demonstrated an aneurysm or pseudoaneurysm of the hepatic artery at the porta hepatis, with possible infiltration into the parenchyma between the right and left lobes of the liver. Selective celiac arteriography showed a 90% stenosis of the right hepatic artery with a large pseudoaneurysm arising from the stenotic segment. This was treated with a 3- × 16-mm stent graft (Jostent; Abbott Vascular, Temecula, Calif) with good result. The completion arteriogram showed wide patency of the stent graft with total exclusion of the pseudoaneurysm. Follow-up serial duplex scans up to 40 months after the procedure showed no evidence of residual pseudoaneurysm and wide patency of the stent graft, with no evidence of focal velocity changes in the right hepatic artery. The patient continues to do well clinically.
Iatrogenic pseudoaneurysms of the extrahepatic arterial vasculature: Management and outcome
2006, HPB
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Patient 3 had undergone embolization prior to presenting to our institution where the vessel was found to be recanalized. Other complications include dislodgement or migration of the obstructing material [6,41], coil erosion into the common bile duct [42], hepatic abscess formation and gallbladder fibrosis [4,24]. Although less common, treatment with stent-graft placement has been reported as an alternative to selective arterial embolization when there is concern about hepatic infarction or vascular recanalization.
Background. Pseudoaneurysms of the extrahepatic arterial vasculature are relatively uncommon lesions following surgery and trauma. In this report we analyze the presentation, management and outcomes of these vascular lesions. Of the related surgical procedures, the reported incidence is highest following laparoscopic cholecystectomy. We hereby analyze the literature on this subject and report our experience, specifically with extrahepatic pseudoaneurysms, drawing an important distinction from intrahepatic pseudoaneurysms. Methods. From September 1995 until July 2004, six patients, including three males and three females with a mean age of 67 years, were treated for seven extrahepatic arterial pseudoaneurysms. Patients were evaluated by endoscopy, ultrasound, computerized tomography, and angiography. Management included coil embolization or arterial ligation and/or hepatic resection. Results. The mean pseudoaneurysm size was 4.9-cm (range 1.0–11.0-cm) and the locations included the right hepatic artery (n = 5), inferior pancreaticoduodenal artery (n = 1), and gastroduodenal artery (n = 1). All six patients had prior surgical or percutaneous procedures. Median latency period between the original procedure and treatment of pseudoaneurysm was 17 weeks (range one month–16 years). Clinical features ranged from the dramatic presentation of hypotension secondary to intraperitoneal aneurysmal rupture to the subtle presentation of obstructive jaundice secondary to pseudoaneurysm mass effect. The range of patient presentations created diagnostic challenges, proving that accurate diagnosis is made only by early consideration of pseudoaneurysm. Management was ligation of the right hepatic artery (n = 4) and embolization of the pseudoaneurysms (n = 2). Post-treatment sequelae included liver failure requiring liver transplant (n = 1), intrahepatic biloma requiring percutaneous drainage (n = 1) and cholangitis with right hepatic duct strictures requiring right lobectomy and biliary reconstruction (n = 1). These complications followed arterial ligation, with no complications resulting from embolization. All six patients are alive and well after a mean follow-up of 53 months. Conclusions. Our six patients demonstrate the diversity and unpredictability with which a pseudoaneurysm of the extrahepatic arterial vasculature may present in terms of initial symptoms, prior procedures, and the latency period between presentation and prior procedure. Through our experience and an analysis of the literature, we recommend a diagnostic and management approach for these patients.
Mycotic pseudoaneurysms after liver transplantation
2005, Transplantation Proceedings
Citation Excerpt :
Stents or percutaneous thrombin injection9–12 may be the technique of choice if they are diagnosed early. Perforation of the biliary duct with stents has been reported.13 Treatment with endoscopic embucrilate injection into fistulas into the bile duct has been described.14
The most frequent etiology of visceral artery aneurysms is arteriosclerosis, but vascular manipulation during hepatic transplantation may also cause a mycotic pseudoaneurysm. Treatment with embolization, stents or percutaneous thrombin injection have been recommended but surgical revascularization is indicated when interventional techniques fail. A 43-year-old man with hepatitis C virus cirrhosis who underwent orthotopic liver transplantation from a cadaveric donor was treated with cyclosporine, mycophenolate, and steroids and was discharged from hospital at 35 days. Two months later he was readmitted with a febrile syndrome. Abdominal computed tomography showed necrosis of hepatic segments IV, V, and VI. Magnetic resonance imaging and angiography revealed partial thrombosis of the hepatic artery and stenosis of the portal anastomosis secondary to an aneurysm of the hepatic artery. A few hours after the radiological diagnosis, the patient suffered a bout of upper gastrointestinal bleeding and shock. Emergency surgery revealed a mycotic pseudoaneurysm of the common hepatic artery, which had ruptured into the bile tract with hemobilia. The liver graft was removed because of severe necrosis of the right liver. The patient died awaiting a new liver transplantation.

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Guglielmi Detachable Coil Erosion into the Common Bile Duct after Embolization of Iatrogenic Hepatic Artery Pseudoaneurysm

Section snippets

CASE REPORT

DISCUSSION

J Vasc Interv Radiol

Nonsurgical management of post-cholecystectomy haemobilia

Br J Surg

Hemobilia due to an hepatic artery pseudoaneurysm thirteen months after laparoscopic cholecystectomy

J Clin Gastroenterol

Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy

Cardiovasc Intervent Radiol

Embolization of an hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Cardiovasc Intervent Radiol