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Cystic Artery Pseudoaneurysm: Current Review of Aetiology, Presentation, and Management. Surg Res Pract 2021; 2021:4492206. [PMID: 34869829 PMCID: PMC8635945 DOI: 10.1155/2021/4492206] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background Cystic artery pseudoaneurysms are rare. Most commonly, they occur secondary to acute cholecystitis or after a cholecystectomy. Complications include haemobilia, biliary obstruction, and haemorrhage. Given the rarity and associated morbidity, a high index of suspicion is required. This article reviews the current literature on cystic artery pseudoaneurysms to investigate its aetiology, clinical presentation, and management options. Methods A broad search of the Medline and PubMed databases was carried through. All peer reviewed literatures published in the English language between 1991 and 2020 with keywords "cystic" and "artery" and "pseudoaneurysm" in the title were selected for review. No further exclusion criteria; all studies yielded from the search were included in the results of this review. Additionally, we present a case of cystic artery pseudoaneurysm treated at our centre and included this in our analysis. Results Sixty-seven case reports were found between 1991 and 2020. Aetiologies: Aetiology of cystic artery pseudoaneurysm was found to be cholecystitis in 41 instances (61.2%), cholecystectomy in 18 instances (26.8%), idiopathic in 6 instances (8.9%) cholelithiasis in 1 instance (1.5%), and pancreatitis in 1 instance (1.5%). Complications: Fifty-two cases were complicated by haemobilia (77.6%), 36 by anaemia (53.7%), 25 by biliary obstruction (37.3%), 13 by haemodynamic shock (19.4%), 9 by haemoperitoneum (13.4%), and 6 by contained rupture (8.9%). Most commonly, patients had two or more of these complications. Management: Forty-four patients were managed with endovascular embolisation (65.7%), 21 with endoscopic intervention (31.3%), 18 with open cholecystectomy (26.9%), 13 with laparoscopic cholecystectomy (19.4%), and 6 with pseudoaneurysm ligation (9%). Delayed presentation postcholecystectomy ranged from 8 days to 3 years. Conclusions Cystic artery pseudoaneurysms are rare complications of a common operation. The most common clinical presentation is haemobilia, which can be difficult to diagnose clinically. A high index of suspicion and prompt investigation with targeted imaging and intervention is required. This is especially pertinent in gastrointestinal bleeding postlaparoscopic cholecystectomy as a missed diagnosis could cause significant morbidity.
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Fujimoto Y, Tomimaru Y, Hatano H, Noguchi K, Nagase H, Hamabe A, Hirota M, Oshima K, Tanida T, Morita S, Imamura H, Iwazawa T, Akagi K, Dono K. Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:187-193. [PMID: 29459583 PMCID: PMC5829622 DOI: 10.12659/ajcr.907273] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Patient: Male, 90 Final Diagnosis: Ruptured cystic artery pseudoaneurysm Symptoms: Epigastric pain • Fever Medication: — Clinical Procedure: Open cholecystectomy Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Yuji Fujimoto
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hisanori Hatano
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan.,Department of Surgery, Rinku General Medical Center, Izumisano, Osaka, Japan
| | - Kozo Noguchi
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hirotsugu Nagase
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Atsushi Hamabe
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masashi Hirota
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kazuteru Oshima
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Tsukasa Tanida
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Shunji Morita
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hiroshi Imamura
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Takashi Iwazawa
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kenzo Akagi
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Keizo Dono
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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Loizides S, Ali A, Newton R, Singh KK. Laparoscopic management of a cystic artery pseudoaneurysm in a patient with calculus cholecystitis. Int J Surg Case Rep 2015; 14:182-5. [PMID: 26291047 PMCID: PMC4573867 DOI: 10.1016/j.ijscr.2015.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 08/04/2015] [Indexed: 11/30/2022] Open
Abstract
Pseudoaneurysm of the cystic artery following acute cholecystitis is rare. It can be safely managed laparoscopically with simultaneous cholecystectomy. This avoids multiple invasive procedures and decreases morbidity associated with open surgery.
INTRODUCTION Pseudoaneurysm of the cystic artery is very rare. In the majority of cases it has been reported as a post-operative complication of laparoscopic cholecystectomy, however it has also been associated with the presence of acute cholecystitis or pancreatitis. When these pseudoaneurysms rupture they can lead to intraperitoneal bleeding, haemobilia and upper gastrointestinal haemorrhage. Radiological as well as open surgical approaches have been described for control of this rare pathology. PRESENTATION OF CASE We report the laparoscopic surgical management of an incidental, unruptured cystic artery pseudoaneurysm in a patient presenting with acute cholecystitis. DISCUSSION Cystic artery pseudoaneurysm is a rare entity and as such there is no consensus on the clinical management of this condition. A variety of treatment strategies have been reported in the literature including radiological selective embolisation and coiling, open cholecystectomy with ligation of the aneurysm, or a two-step approach involving radiological management of the pseudoaneurysm followed by an elective cholecystectomy. CONCLUSION In this report we have demonstrated that laparoscopic management of a cystic artery pseudoaneurysm with simultaneous laparoscopic cholecystectomy is feasible and safe. This avoids multiple invasive procedures and decreases morbidity associated with open surgery.
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Affiliation(s)
- Sofronis Loizides
- Department of Upper Gastrointestinal Surgery, Ashford and St Peters NHS Trust, UK
| | - Asad Ali
- Department of Upper Gastrointestinal Surgery, Ashford and St Peters NHS Trust, UK.
| | - Richard Newton
- Department of Upper Gastrointestinal Surgery, Ashford and St Peters NHS Trust, UK
| | - Krishna Kumar Singh
- Department of Upper Gastrointestinal Surgery, Worthing Hospital, Western Sussex NHS Trust, Worthing, UK
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Shelmerdine SC, Ameli-Renani S, Lynch JO, Gonsalves M. Transarterial catheter embolisation for an unusual cause of upper gastrointestinal haemorrhage. BMJ Case Rep 2015; 2015:bcr2014206837. [PMID: 26021378 PMCID: PMC4458594 DOI: 10.1136/bcr-2014-206837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2015] [Indexed: 11/03/2022] Open
Abstract
A 72-year-old man with a history of gallstones, and complex cardiac and endocrinological comorbidities, presented with severe abdominal pain and melaena. CT mesenteric angiogram showed a cystic artery pseudoaneurysm and gallbladder distended by haematoma. Subsequent mesenteric angiography confirmed a cystic artery pseudoaneurysm, which was successfully embolised with microcoils. The patient made a rapid recovery and was discharged after 3 days.
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Affiliation(s)
| | | | - Jeremy Oliver Lynch
- Department of Clinical Radiology, Chelsea and Westminster Hospital, London, UK
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Unruptured cystic artery pseudoaneurysm accompanied by Mirizzi syndrome: a report of a case. Clin J Gastroenterol 2013; 6:490-5. [DOI: 10.1007/s12328-013-0434-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 10/11/2013] [Indexed: 10/26/2022]
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Pseudoaneurism of the cystic artery treated with hyperselective embolisation alone. Diagn Interv Imaging 2013; 94:641-3. [DOI: 10.1016/j.diii.2012.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Radouane B, Jidal M, EL Fenni J, Chaouir S, Amil T, Hanine A, Benameur M. Pseudo-anévrisme de l’artère cystique secondaire à une cholécystite lithiasique : à propos d’un cas. ACTA ACUST UNITED AC 2008; 89:345-6. [DOI: 10.1016/s0221-0363(08)93010-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Akatsu T, Tanabe M, Shimizu T, Handa K, Kawachi S, Aiura K, Ueda M, Shimazu M, Kitajima M. Pseudoaneurysm of the cystic artery secondary to cholecystitis as a cause of hemobilia: report of a case. Surg Today 2007; 37:412-7. [PMID: 17468824 DOI: 10.1007/s00595-006-3423-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 12/04/2006] [Indexed: 02/07/2023]
Abstract
Spontaneous intracholecystic bleeding is very rare. We report herein a very rare case of a pseudoaneurysm of the cystic artery due to acute cholecystitis. A 58-year-old man presented at the emergency department complaining of colicky pain in the right upper quadrant. Dynamic magnetic resonance imaging demonstrated an early-enhanced pooling of contrast material (suggestive of a pseudoaneurysm of the cystic artery) inside the neck of the gallbladder. After the proximal control of the hepatic artery, the patient underwent a cholecystectomy and a ligation of the cystic artery. The resected specimen of the gallbladder showed evidence of a massive intracholecystic hematoma. Proximal to the impacted gallstone in the neck, a 2-cm diameter saccular-type pseudoaneurysm was identified. Although a pseudoaneurysm of the cystic artery is very rare, it should be included in the differential diagnosis of hemobilia. Once the pseudoaneurysm is confirmed, its embolization before a cholecystectomy (which can be attempted laparoscopically) may be useful to ensure the safety of the patient.
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Affiliation(s)
- Tomotaka Akatsu
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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Saluja SS, Ray S, Gulati MS, Pal S, Sahni P, Chattopadhyay TK. Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature. BMC Gastroenterol 2007; 7:12. [PMID: 17386110 PMCID: PMC1851966 DOI: 10.1186/1471-230x-7-12] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 03/26/2007] [Indexed: 01/04/2023] Open
Abstract
Background Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone. Case presentation We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done. Conclusion This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.
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Affiliation(s)
- Sundeep S Saluja
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Sukanta Ray
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Manpreet S Gulati
- Department of Radiology Ground floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Sujoy Pal
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Peush Sahni
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Tushar K Chattopadhyay
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
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