Hemobilia due to cystic artery pseudoaneurysm following cholecystectomy: diagnosis and management, a case report

Transcatheter arterial embolization of cystic artery bleeding

Purpose

The purpose of this study is to assess the safety and clinical outcomes of transcatheter arterial embolization (TAE) via the cystic artery for treating patients with bleeding from the cystic artery.

Materials and Methods

This retrospective study included 20 patients who underwent TAE via the cystic artery between January 2010 and May 2022. Radiological images and clinical data were reviewed to evaluate causes of bleeding, procedure-related complications, and clinical outcomes. Technical success was defined as the disappearance of contrast media extravasation or pseudoaneurysm, as demonstrated on completion angiography. Clinical success was defined as discharge from the hospital without any bleeding-related issues.

Results

Hemorrhagic cholecystitis (n = 10) was the most common cause of bleeding, followed by iatrogenic (n = 4), duodenal ulcer (n = 3), tumor (n = 2), and trauma (n = 1). Technical success was achieved in all cases, and clinical success was achieved in 70% (n = 14) of patients. Three patients developed ischemic cholecystitis as a complication. Six patients with clinical failure died within 45 days after embolization.

Conclusion

TAE through the cystic artery has a high technical success rate in treating cystic artery bleeding, but clinical failure remains a common occurrence due to concurrent medical conditions and the development of ischemic cholecystitis.

Beware of Rattling Underfoot: Cystic Artery Pseudoaneurysm in Acute Cholecystitis With a Cholecystostomy

Cystic artery pseudoaneurysm (CAP) is a very rare complication of acute cholecystitis. The pathogenesis of CAP in the context of cholecystitis is unknown but is possibly related to the inflammatory process in the vicinity of the cystic artery, leading to weakness in the wall of the artery. Though CAP has been reported in the literature, our patient had a unique presentation in the presence of a cholecystostomy catheter in situ. There were no risk factors for CAP in our patient including usage of anticoagulants, trauma, or surgical procedures. Fortunately, the blood-stained fluid in the cholecystostomy catheter effluent alerted the clinical team to a possible vascular complication in the background of ongoing cholecystitis. This finding should serve as a warning sign to alert clinicians to the possibility of CAP-beware of rattling underfoot.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

Background

Iatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.

Case presentation

We report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.

Conclusions

Even with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.