Hemobilia after pseudoaneurysm of a right hepatic artery branch

Unsuccessful Stent Graft Repair of a Hepatic Artery Aneurysm Presenting with Haemobilia: Case Report and Comprehensive Literature Review

Aims

To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature.

Methods

Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected.

Results

A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months.

Comprehensive literature review

Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder.

Conclusions

Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings.

In patients presenting with haemobilia in the presence of a non-traumatic and non-iatrogenic hepatic artery aneurysm•

Endocarditis and cholecystitis are the most common causes

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The main treatment modality is embolisation

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Liver ischaemia and liver abscesses have not been reported after treatment

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Close surveillance is recommended as the area has to be considered contaminated

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Treatment should be performed by a multidisciplinary team

An insidious case of hepatic artery pseudoaneurysm secondary to acalculus cholecystitis

A 68-year-old man with expressive dysphasia presented with upper gastrointestinal haemorrhage, jaundice and abdominal pain. He was unable to tolerate ultrasound tranducer pressure. His oesophagogastroduodenoscopy (OGD) showed large blood clots in the stomach with blood trickling from the ampulla. An urgent CT angiogram demonstrated a 32 mm pseudoaneurysm within the gallbladder fossa. The patient subsequently underwent an endovascular embolisation of the pseudoaneurysm performed by the interventional radiology team.