Intrahepatic Artery Pseudoaneurysm-induced Hemobilia Caused by a Plastic Biliary Stent After ABO-incompatible Living-donor Liver Transplantation: A Case Report

Hepatic artery pseudoaneurysm-the Mayo Clinic experience and literature review

Introduction

Hepatic artery pseudoaneurysm (HAP) is a rare and potentially life-threatening condition associated with high mortality. This study aims to review the etiology, clinical manifestations, management, and outcomes of patients diagnosed and treated for HAP at the Mayo Clinic.

Methodology

This study was a retrospective chart review of medical records for patients diagnosed and treated for hepatic artery pseudoaneurysm (HAP) at the Mayo Clinic (Florida, Minnesota, and Arizona) between September 1, 1998, and June 30, 2022. A total of 27 patients with HAP were identified, and their demographics, presenting symptoms, location of HAP, etiology, associated liver pathology, type of intervention, and outcomes were analyzed.

Results

The majority of patients with hepatic artery pseudoaneurysm (HAP) were male (63%), with a median age of 57 years (range: 25-87 years). HAP was predominantly intrahepatic (85.2%) and most commonly located on the right hepatic artery (RHA) (70.4%). In 89.9% of cases, the condition was attributable to hepatobiliary procedures or trauma, while only 10.1% occurred spontaneously. Presenting symptoms at the time of HAP diagnosis varied, including gastrointestinal (GI) bleeding (29.6%), abdominal pain (14.81%), non-GI bleeding (11.1%), traumatic bodily injury (11.1%), and other symptoms (14.81%). Asymptomatic or incidental findings of HAP were observed in 18% of cases. Malignancy was identified in 52% of patients, and 26% were liver transplant recipients. Statistical analysis revealed that factors such as prior knowledge of HAP (p = 0.381), HAP rupture (p = 0.382), anticoagulation therapy (p = 0.856), hemorrhagic shock (p = 0.25), liver cirrhosis (p = 0.143), gastrointestinal bleeding (p = 0.879), hepatobiliary abscess (p = 0.079), liver transplantation (p = 0.738), spontaneous HAP (p = 0.381), and malignancy (p = 0.163) were not significantly associated with increased mortality. In contrast, the need for transfusions (p = 0.021), tumor invasion (p = 0.023), portal vein thrombosis (PVT) (p = 0.02), and liver necrosis (p = 0.02) were significantly associated with higher mortality. The overall infection rate was 3%, while the mortality rate was 18.5%.

Discussion

Hepatic artery pseudoaneurysm (HAP) is a rare but serious condition often associated with hepatobiliary procedures, trauma, or liver transplants, though it can also occur spontaneously. While HAP is commonly detected incidentally, its diagnosis is frequently linked to complications such as rupture and gastrointestinal bleeding. However, our study suggests that these complications do not necessarily increase mortality. Key factors associated with higher mortality include the need for blood transfusions, tumor invasion, portal vein thrombosis, and liver necrosis at the time of diagnosis. The overall infection rate was low, but the mortality rate was 18.5%, highlighting the importance of early detection and management.

Massive duodenal ulcer bleeding due to the ruptured hepatic artery pseudoaneurysm after living donor liver transplantation

BACKGROUND

The rupture of a hepatic artery pseudoaneurysm (HAP) is a rare but lethal complication after living donor liver transplantation (LDLT) and often manifests as acute gastrointestinal bleeding.

CASE PRESENTATION

This report describes three patients who experienced HAP after LDLT. These patients initially presented with active bleeding of a duodenal ulcer (DU) in the duodenal bulb, followed by diagnosis of the ruptured HAP by angiography. None of the patients had evidence of an active intra-abdominal infection or bile leakage preceding the rupture of HAP. All patients were initially treated by transcatheter arterial coil embolization (TAE). In all cases, TAE was successful for hemostasis but resulted in complete obstruction of the arterial inflow to the graft. Arterial revascularization by surgical reconstruction using the autologous arterial graft in one case and re-LDLT in another one was successfully performed. The other one succumbed to sepsis caused by later liver abscesses.

CONCLUSION

This is the first detailed case series of massive DU bleeding as a warning signal of ruptured HAP after LDLT. HAP should be included in the differential diagnosis when an LDLT recipient presents with gastrointestinal bleeding.

Rupture of Pseudoaneurysm after Biliary Metallic Stent Placement

Rupture of a pseudoaneurysm (PA) has been reported as a rare but serious adverse event associated with endoscopic biliary stenting. We herein report 2 cases of severe biliary bleeding from a PA that developed 10-14 days after placement of a self-expandable metallic stent (SEMS) for biliary malignancy. The first patient was successfully embolized with endovascular coiling. However, the second patient had wide-spreading cholangiocarcinoma and, despite being treated once by full coiling, developed a second rupture of PA two months after starting systemic chemotherapy. Clinicians should be aware of the possibility of PA and carefully follow stented patients after endovascular treatment.

Massive hemobilia following plastic stent removal in common bile duct cancer associated with primary sclerosing cholangitis (with video)

Hemobilia is defined as bleeding into the biliary tract. Herein, we report a very rare case of massive hemobilia following plastic stent (PS) removal in common bile duct (CBD) cancer. A 72-year-old man with primary sclerosing cholangitis had undergone repeated insertion of a PS into the CBD. Biliary tract biopsy was performed based on suspicion of combined CBD cancer. Biopsy revealed poorly differentiated adenocarcinoma of the CBD. One month after the biliary tract biopsy, he was admitted for acute cholangitis, and endoscopic retrograde cholangiography was performed for the exchange of the PS. When one of the two biliary PSs was removed, spurting bleeding from the major papilla began abruptly. The massive bleeding caused the patient to be in a pre-shock state. A retrieval balloon catheter was compressed against the papilla for hemostasis. Although he was treated conservatively, the patient developed a bloody discharge. Upper gastrointestinal endoscopy revealed that the pulsatile bleeding beside the PSs started immediately after the removal of the coagula. Emergent contrast-enhanced computed tomography showed right hepatic artery aneurysm across the CBD. Therefore, transarterial embolization was performed. The patient's post-therapeutic course was uneventful. He received chemotherapy, but died about a half year after hemobilia occurred.