Bleeding after percutaneous transhepatic biliary drainage due to arterial injury: A case study in patient with stable hemodynamic

Abstract

Percutaneous transhepatic biliary drainage (PTBD) is an effective procedure for correcting biliary obstructions. It can be performed under ultrasound and fluoroscopic equipment; however, it may entail serious complications, including bleeding, caused by arterial or venous injury. We present a 49-year-old man presented with a 1-month history of icterus, jaundice, dark urine, and right hypochondrial pain. MR imaging discovered a dilatation of the right intrahepatic bile duct due to obstruction by intrahepatic cholangiocarcinoma. PTBD procedure was performed in the right intrahepatic bile duct. After the pigtail drain device was inserted, the bile fluid color that came out from the pigtail turned sanguineous; nonetheless, the patient's hemodynamic was stable. Therefore, the second cholangiography was performed for evaluation. Some resistance was sensed during contrast injection into the bile duct, and the operator pushed the contrast media a little bit stronger and found a filling defect formed by a clot in the bile duct that suggested high suspicion of vessel injury. Although the patient's hemodynamics was still stable, the operator quickly decided to perform a hepatic arteriography procedure because bright red blood through the tube and a relatively rapid clot formed from the puncture point and distal drain, which were signs of hepatic artery injury. Hepatic arteriography confirmed the location of pseudoaneurysm caused by vessel trauma and arterio-intrahepatic bile duct fistulation. The embolization procedure was performed using PVA-300 into a ruptured hepatic artery branch through a microcatheter. Re-evaluation arteriography showed no pseudoaneurysm or arterio-intrahepatic bile duct fistulation after embolization.

Keywords: Arteriography; Cholangiography; Embolization; Percutaneous transhepatic biliary drainage.

Fig. 1

Abdominal MRI; (A) T2 FS sequence coronal view showed the dilatation followed by an abrupt termination of right intrahepatic bile duct; (B) 3D MRCP clearly showed the dilatation of right hepatic bile duct; (C) T1 FS contrast showed the contrast-enhanced mass (red arrow) that obstruct the right intrahepatic bile duct. © Department of Radiology, Dr. Soetomo General Academic Hospital, Medical Faculty of Universitas Airlangga, Surabaya, Indonesia (with permission).

Fig. 2

Percutaneous cholangiography; (A) introducer placed in large intrahepatic bile duct and contrast injected into the bile duct; (B) the contrast filled in the right intrahepatic bile duct and stopped. There was no contrast filling the left hepatic bile duct, common hepatic bile duct, or the common bile duct. No leaked contrast media was found in this image. © Department of Radiology, Dr. Soetomo General Academic Hospital, Medical Faculty of Universitas Airlangga, Surabaya, Indonesia (with permission).

Fig. 3

Pigtail drain device fixated inside the intrahepatic bile duct; (A) pigtail visualized inside intrahepatic bile duct; (B) contrast injected through the pigtail, there is filling defect in the intrahepatic bile duct (blue arrow). © Department of Radiology, Dr. Soetomo General Academic Hospital, Medical Faculty of Universitas Airlangga, Surabaya, Indonesia (with permission).

Fig. 4

Hepatic arteriography; (A) contrast media was injected through a catheter and filled the hepatic arteries. A contrast pool was evident at the distal hepatic artery (blue arrow), a branch of the intrahepatic bile duct (star); (B) Selective arteriography using microcatheter. The contrast pool at the distal hepatic artery forming a pseudoaneurysm was strongly visible (arrow). There was also artery-intrahepatic bile duct fistulation as contrast fills around pigtail (arrowhead) drain and intrahepatic bile duct (star). © Department of Radiology, Dr. Soetomo General Academic Hospital, Medical Faculty of Universitas Airlangga, Surabaya, Indonesia (with permission).

Fig. 5

Embolization at hepatic artery branch; (A & B) PVA-300 was injected into the ruptured artery branch (white arrow). (C) Evaluation after embolization showed no pseudoaneurysm and artery-bile duct fistula. © Department of Radiology, Dr. Soetomo General Academic Hospital, Medical Faculty of Universitas Airlangga, Surabaya, Indonesia (with permission).