Dual pathology, single solution: concurrent bile duct injury and hepatic artery pseudoaneurysm managed by interventional radiology after converted cholecystectomy

Abstract

Introduction:

Laparoscopic cholecystectomy (LC) is the gold standard for gallbladder pathologies, but carries risks of bile duct injury (BDI) and vascular complications, such as hepatic artery pseudoaneurysm (HAP). While BDI occurs in 0.3–0.5% of cases, HAP is rare (0.8%), with concurrent injuries being exceptionally uncommon.

Case presentation:

A 31-year-old male who developed BDI and HAP after LC was managed successfully through interventional radiology (IR). The patient was managed by LC, which was converted to an open cholecystectomy, and presented with complaints of fever, vomiting, and abdominal pain for 8 days. Angioembolization of the 4.5 mm HAP via a covered stent in the common hepatic artery and computed tomography-guided drainage of a large infected biloma were performed. Persistent bile leak required percutaneous transhepatic biliary drainage (PTBD). After the procedure, the patient’s condition improved drastically, and the patient was discharged without complications.

Discussion:

IR plays a significant role in the identification and treatment of biliary lesions. IR’s key part in dealing with dual complications and suggests a minimally invasive alternative to reoperation. Isolated BDI or HAP has been documented, but the co-occurrence of BDI or HAP is rare, and there is limited literature on IR-based management.

Conclusion:

The combined use of angioembolization and biliary drainage highlights a minimally invasive and effective approach to avoid the need for further surgical intervention. This case report provides valuable insight into the management of dual complications.

Introduction

Laparoscopic cholecystectomy (LC) is performed for various gallbladder pathologies, such as acute or chronic cholecystitis, symptomatic cholelithiasis, biliary dyskinesia, hypofunction or hyperfunction, acalculous cholecystitis, gallstone pancreatitis, and gallbladder masses/polyps. In Pakistan, LC rates are 32%, 80%, and 21.3%, according to reports by Iqbal et al, Abasis et al, and Raza et al, respectively^[1]. Compared to developed countries, these rates are lower in Pakistan primarily due to the limited availability of skilled surgeons and adequate surgical equipment. Some complications of LC include common bile duct injuries (BDIs), surgical wound infection, intra-abdominal collection, incisional hernia, hematoma of the abdominal wall, gall bladder carcinoma, and lost gallstones (abscess)^[2]. BDI is an unexpected and potentially catastrophic complication of elective cholecystectomy. It usually necessitates invasive treatment and is associated with severe morbidity and fatality. There have been reports of fatality rates of 2–4% and short-term morbidity rates of up to 40–50% for significant injuries^[3].

HIGHLIGHTS

• Exceptional rarity of concurrent BDI and HAP post-LC.

• The sequential IR techniques (angioembolization → PTBD → stent) as a novel alternative to surgery.

• Recommend early IR consultation for post-LC complications to avoid delays.

• Importance of the Integrated role of IR, surgery, and gastroenterology in diagnosing and managing complex post-LC complications.

Despite being minimally invasive, LC has a documented rise in both vascular and biliary injuries. Vascular complications such as pseudoaneurysms (PSAs) also occur at an approximate rate of 0.8%^[4]. Late arterial bleeding can result in the formation of PSA in the right hepatic or cystic artery. Individuals with postoperative PSAs may experience hemobilia or hemoperitoneum. Post-cholecystectomy PSAs most commonly involve the right hepatic artery (87.1%), followed by the cystic artery (7.9%), both arteries concurrently (4.0%), and the gastroduodenal artery (1.0%)^[5]. Interventional radiological techniques play a significant role in managing these complications, as they can provide a preoperative anatomic definition of the extent of injury as well as catheter localization of the intrahepatic duct^[6]. Interventional radiology (IR) also manages PSAs by either inserting an arterial stent or coiling at the neck of the aneurysm^[7]. We report this case due to the rare coexistence of BDI and hepatic artery pseudoaneurysm (HAP) in a single patient, both successfully managed with IR. It is seldom seen in the literature, as most published cases have only one injury that was treated by IR or other techniques. This case report has been reported in line with the SCARE Criteria^[8].

Case presentation

A 31-year-old male with a history of cholelithiasis, for which he was managed with LC and converted to open cholecystectomy due to BDI, presented on the 20th postoperative day to the surgery department with complaints of fever, vomiting, and abdominal pain for a total duration of 8 days. On clinical examination, he appeared pale and jaundiced, and systemic examination revealed a distended abdomen with tenderness in the epigastric region. The patient was admitted to the gastroenterology department.

A preliminary diagnostic workup was carried out that revealed significant findings at the time of admission like raised C-reactive protein 215 mg/L (normal range is 0–10 mg/L), deranged liver function tests (LFTs), increased international normalized ratio; 1.4 (normal is 0.9–1.2), pus culture obtained from abdominal fluid showed heavy growth of Klebsiella species, etc. A contrast-enhanced CT of the abdomen revealed a small, rounded arterial outpouching measuring 4.5 mm from the hepatic artery, suggesting a PSA at the cystic artery stump site (Fig. 1a). Ultrasound scan before surgery showed no aneurysm. Furthermore, CT revealed a large air-containing collection in the gallbladder fossa, extending into the mesentery, gastrohepatic ligament, and subhepatic region. It measured approximately 16.6 × 6.4 × 10.2 cm, along with corresponding inflammatory changes in the gallbladder fossa, lesser sac, mesentery, and pancreas head and body, suggesting acute necrotizing pancreatitis with intra-abdominal fluid collection. Magnetic resonance cholangiopancreatography was done to see the bile leak.

Figure 1.

Contrast-enhanced CT abdomen and right hepatic artery angiogram. (A) Contrast-enhanced CT abdomen in the arterial phase shows a tiny focal rounded arterial outpouching arising from the right hepatic artery, representing a pseudoaneurysm at the cystic artery stump site (arrow). No active contrast extravasation is noted to suggest arterial bleeding. (B) Selective cannulation of the right hepatic artery angiogram showed a small pseudo-aneurysm (white arrow) arising from mid right hepatic artery adjacent to the site of cholecystectomy clips. (C) A CT-guided drainage catheter was inserted into the gallbladder fossa to address the intra-abdominal fluid collection (arrows).

To manage these complications, vascular IR procedures, including angioembolization of the PSA, were performed. The right femoral artery was punctured, and a 6 French (Fr) vascular sheath was placed in the right femoral artery using the Seldinger technique. A 4 Fr Cobra (C1) catheter over the compatible glide wire was used to selectively cannulate the celiac and superior mesenteric arteries. A covered stent with a 6 Fr sheath was deployed across the common hepatic artery to restore flow in the hepatic artery, leading to successful exclusion of the aneurysm (Fig. 1b). A CT-guided drainage catheter was also placed in the gallbladder fossa to manage intra-abdominal fluid collection (Fig. 1c). A bile leak from the common BDI was identified, for which an external-internal biliary drain was placed using a vertebral catheter and glide wire to access the duodenum (Fig. 2a–b). After wire exchange, an 8 Fr internal–external biliary drain was placed. The patient’s symptoms were alleviated, and the patient was subsequently discharged without any complications and was advised to adhere to follow-ups. A 10 × 70 mm covered self-expandable metal stent was selected for placement across the common BDI due to its superior ability to seal leaks and maintain luminal patency in the setting of major ductal disruption. The stent extended into the duodenum, and its position was confirmed on follow-up cholangiogram showing adequate biliary drainage (Fig. 2c).

Figure 2.

Cholangiogram. (A–B) Bile leakage from the common bile duct due to injury led to the placement of an internal–external biliary drain. A vertebral catheter and glide wire were used for access, followed by an 8 Fr drain placement (B). (C) Biliary stent in the CBD with its tip in the duodenum (arrow) and cholangiogram showing patent stent (arrow) flowing freely into the duodenum (arrowhead).

A bolus of 5000 units of unfractionated heparin was administered intra-arterially at the time of stent deployment. Post-procedure, the patient was maintained on dual antiplatelet therapy (aspirin 75 mg and clopidogrel 75 mg daily) for 3 months, followed by aspirin monotherapy, to ensure hepatic artery stent patency.

At follow-up visits, the patient was asymptomatic, with normal LFTs. He reported no recurrence of pain, fever, vomiting, or signs of infection. There were no episodes of gastrointestinal bleeding, no signs of liver dysfunction, and no further need for readmission. The patient made a full recovery after 4 months of treatment and was regularly followed for 6 months with instructions to report to the hospital immediately if any complaints of fever, persistent vomiting, and abdominal distension.

Discussion

LC has become the preferred treatment for gallbladder pathologies worldwide. Its popularity over classical cholecystectomy is due to its minimally invasive nature, enhanced safety, fewer postoperative complications, quicker recovery, and significantly shorter hospital stay^[9]. Biliary complications of this procedure include injury to the right hepatic duct, common bile duct, or gallbladder perforation with spilled calculi. Additionally, there are non-biliary complications, such as iatrogenic pneumothorax and intestinal, diaphragmatic, and vascular injuries.

IR is the preferred treatment for HAPs and bile leaks after cholecystectomy in a hemodynamically stable patient with an injury contained without transection, and defined on imaging in the early stage. IR is particularly beneficial in patients at high risk for surgery because of sepsis or significant inflammation, as IR can cure the pathology minimally invasively with less morbidity than open surgery. In this case, IR enabled efficient exclusion of PSA with a covered stent and bile leak healing with drainage and stenting, avoiding complicated surgery in an otherwise relevant intra-abdominal infection patient. The modality is linked with faster recovery, shorter hospital stay, and fewer complications where skill and imaging capability are available^[1,2].

BDI following cholecystectomy may lead to severe complications like persistent bile leak leading to bile peritonitis, which may extend to abdominal sepsis, fever, pain, and prolonged recovery. In the long run, BDI may cause the formation of biliary strictures leading to chronic cholangitis, progressive liver failure, or secondary biliary cirrhosis. Obstructive jaundice may follow external compression or internal stenosis of the bile ducts, and recurrent cholangitis is a danger if drainage of bile remains poor. Hepaticojejunostomy, with dangers of stricture, leak, or breakdown of the anastomosis, may be necessary for major injuries^[1–3]. HAP, though rare, carries a high risk of rupture with massive hemoperitoneum or hemobilia and hemorrhagic shock, compression of adjacent structures with biliary obstruction or ischemia, infection of the hematoma or PSA sac as a secondary complication, and hepatic infarction if there is compromised arterial supply^[4,5].

Interventional therapies, though effective, are also dangerous. Endovascular treatment of HAP using covered stents or embolization can result in re-bleeding or failure to exclude the PSA with the need for repeat intervention, hepatic ischemia or infarction if there is a failure of arterial supply, stent thrombosis or migration with compromised hepatic perfusion, contrast-induced nephropathy, and vascular access site problems including hematoma, PSA, or arterial dissection. Percutaneous biliary drainage or stenting is also at risk of catheter dislodgement or occlusion, leading to recurrent bile leak or cholangitis, infection or abscess along the catheter tract, bleeding secondary to puncture or liver capsule, injury to adjacent organs such as bowel perforation, and stent migration or occlusion with subsequent biliary obstruction and return of symptoms^[6,7].

Concurrent bile duct and hepatic artery damage have been reported as consequences of LC in the case study by Mistry and Vala^[10], but this case report, although having the same scenario of two injuries occurring in the same patient, highlights the rare management of both pathologies by IR. In our case, LC was identified as the cause of HAP, despite the prevalence of PSAs in the context of BDI during LC being only 2.6–4.5%^[7], which accounts for the rarity of the case. Patients with HAP often present with jaundice, changes in the LFT profile, gastrointestinal bleeding (hemobilia) in the form of hematemesis or melena, and abdominal pain or discomfort. Many of these symptoms were observed in our patient. The most effective imaging test for identifying hepatic artery damage after LC is multiphasic contrast computed tomography (CT). In our case, contrast-enhanced CT verified the existence of a HAP, as documented by Gandhi et al^[11]. Summary of key literature on dual pathology: BDI and HAP post-LC are included in Table 1.

Table 1.

Summary of key literature on dual pathology: bile duct injury and hepatic artery pseudoaneurysm post-laparoscopic cholecystectomy

Reference (year)	Pathologies	IR management	Presentation	Outcome
Rivitz et al (1996)[12]	Hepatic artery pseudoaneurysm (HAP) with bile duct communication post-LC	Transarterial embolization (TAE)	Hemobilia, bileleak	Successful embolization, resolution of bleeding, no further surgery
Senthilkumar et al (2016)[13]	Multiple symptomatic HAPs (some with bile leak)	Coil embolization or glue embolization	RUQ pain, fever, hemobilia	Successful in all patients, no surgical intervention needed
Nicholson et al (1999)[14]	HAP post-LC with bile duct involvement	Angiographic embolization	Hemobilia, biliary symptoms	Good recovery, no surgical repair required
El Badri et al (2021)[15]	HAP compressing bile duct, no rupture	No IR – spontaneousthrombosis observed	Obstructive jaundice	Resolved spontaneously, no procedure required

IR is the preferred treatment for HAPs and bile leaks after cholecystectomy in a hemodynamically stable patient with an injury contained without transection, and defined on imaging in the early stage. IR is particularly beneficial in patients at high risk for surgery because of sepsis or significant inflammation, as IR can cure the pathology minimally invasively with less morbidity than open surgery. In this case, IR enabled efficient exclusion of pseudoaneurysm with a covered stent and bile leak healing with drainage and stenting, avoiding complicated surgery in an otherwise relevant intra-abdominal infection patient. The modality is linked with faster recovery, shorter hospital stay, and fewer complications where skill and imaging capability are available^[16,17].

Existing practice guidelines and expert opinions from organizations like the Society of Interventional Radiology and European Society for Vascular Surgery advocate endovascular and percutaneous techniques as primary treatment for visceral artery PSAs based on their technical success, reduced morbidity, and avoidance of open surgery^[18,19]. For BDI, Tokyo Guidelines 2018 also emphasize early percutaneous or endoscopic repair of the bile leak before surgical reconstruction, particularly in septic patients or for localized bile collections^[20,21].

In addition to HAP, BDI is also a serious LC complication that significantly lowers the patient’s quality of life^[22], and 80–85% of BDIs are caused by LC, which is complicated and difficult to manage^[23]. The type and extent of the injury will determine the most appropriate step, which may involve surgical, percutaneous, or endoscopic procedures. IR plays a significant role in the identification and treatment of biliary lesions. It is possible to perform percutaneous transhepatic cholangiography with or without decompression, which involves the implantation of an external drainage catheter for initial diversion. This procedure allows time for the patient’s clinical status to improve and for postoperative swelling and inflammation to subside while also providing anatomic delineation for future therapeutic planning. If desired, the external drain can be changed to an internal/external drain after approximately 2–4 days^[17]. Although the precise frequency of combined microvascular injury is uncertain, it seems to occur more frequently than anticipated. Care of these injuries after LC can be challenging. IR offers a less invasive and effective alternative for managing combined microvascular injuries.

This case report highlights the use of IR for successful diagnosing and managing the rare dual complication, BDI and hepatic artery pseudoaneurys. This showed the importance of a minimally invasive alternative to surgery. It provides valuable clinical insight into IR’s role in complex post-LC cases. However, its single-patient focus, lack of long-term follow-up, and absence of comparative treatment analysis cannot be generalized to all patients with similar complications.

Conclusion

In conclusion, this case underscores the rare occurrence of concurrent BDI and HAP after LC. Both complications were successfully managed using IR, demonstrating their crucial role in treating complex cases. The combined use of angioembolization and biliary drainage highlights a minimally invasive and effective approach to avoid the need for further surgical intervention. This case report provides valuable insights into the management of post-LC dual complications, which are seldom seen in the medical literature.

Ethical approval

Not required.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

B.Z., T.U.H.: conceived and designed the study. M.M.Z.U., H.A., A.T., A.N., J.I.: conducted the research and assisted with methodology development. M.M.Z.U., H.A., A.T., A.N., J.I., and J.G.: wrote the first draft of this manuscript. All authors were involved in revising the manuscript and approved the final submitted version.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Guarantor

Burhan Zafar, Huzafa Ali, and Jeevan Gyawali.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

It will be open access and publicly available as per the journal guidelines.

Data sharing

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Using artificial intelligence (AI)

The authors used artificial intelligence (AI)-assisted technologies to check grammar errors.

Clinical trial

Not applicable.