Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer

Abstract

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Keywords: Pseudoaneurysm; Self-expandable metallic stents; Sonazoid; Transcatheter arterial embolization; Wallstent.

Figure 1

Computed tomography image obtained 5 mo after self-expandable metallic stent insertion showed no abnormal findings of the right hepatic artery (arrow).

Figure 2

Computed tomography showed a small pseudoaneurysm of the right hepatic artery, measuring 9 × 6 mm, protruding into the common bile duct lumen (arrow) 9 mo after self-expandable metallic stent insertion.

Figure 3

On the 2nd hospital day, an endoscopic naso-biliary drainage and a plastic stent were placed into the self-expandable metallic stent. On the 6th hospital day, axial (A) and coronal (B) plane arterial phase computed tomography showed enlargement of the pseudoaneurysm (arrow).

Figure 4

Color Doppler ultrasonography on the 6th hospital day. A: Ultrasonography showed marked dilation of the common bile duct to a diameter of 24 mm and consequent extrinsic compression of the portal vein; B:The self-expandable metallic stent (SEMS) was displaced toward the liver, and hypoechoic solid components filling the space between the SEMS and bile duct and a pseudoaneurysm showing cystic growth in the lumen of the bile duct was observed; C: Only the apex of the pseudoaneurysm was in contact with the SEMS.

Figure 5

The pseudoaneurysm and hypoechoic solid components filling the dilated bile duct were examined on contrast-enhanced ultrasonography. A-C: Images obtained at 15 s (A), 55 s (B) and 127 s (C) after injection of Sonazoid (0.5 mL) via a left cubital venous line showed no Sonazoid bubbles in the common bile duct other than in the pseudoaneurysm; D: Monitor B-mode ultrasonography image.

Figure 6

Transcatheter arterial embolization performed on the 12th hospital day. A, B: On angiography, the left and right hepatic arteries were found to arise from the superior mesenteric artery, and the pseudoaneurysm was confirmed to be located in the right hepatic artery; C: One IDC coil was placed in the right hepatic artery on the distal side of the pseudoaneurysm (arrow) after the pseudoaneurysm was framed using several types of coils. Seven coils were placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method.