Rupture of Pseudoaneurysm after Biliary Metallic Stent Placement

Abstract

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.

Keywords: TAE; biliary stenting; pseudoaneurysm; rupture; treatment.

Figure 1.

Endoscopic retrograde cholangiopancreatography (ERCP) views of case 1. ERCP demonstrating multiple stenoses within the hilar and common bile duct (arrowhead) (a). The diameter of bile duct was 10 mm. Two self-expandable metallic stents (SEMS) were placed in series from the intrahepatic bile duct to the duodenum (b).

Figure 2.

Computed tomography (CT) and angiography of case 1. CT showing a pseudoaneurysm (PA) (arrowhead) within the biliary stent (a). A selective right hepatic artery angiogram demonstrating the PA before (b) and after (c) coil embolization.

Figure 3.

ERCP images of case 2. ERCP demonstrating a long stretch of stenosis in the common bile duct (a). The diameter of the bile duct was 8 mm. Two SEMSs were placed in a partial stent-in-stent formation from the left and right hepatic ducts to the lower common bile duct.

Figur 4.

CT and angiography of case 2. CT showing a PA arising from the posterior superior branch of the pancreatoduodenal artery, recognized as being within the SEMS (arrowhead) (a). Angiography demonstrating an aneurysm of the posterior superior branch of the pancreatoduodenal artery (b) and the cessation of inflow after coil embolization (c).