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A 59 year-old woman with liver cirrhosis due to hepatitis C, complicated by refractory hepatic hydrothorax was treated with a TIPS (transjugular intrahepatic portosystemic shunt) procedure. The procedure was complicated by substantial gastrointestinal hemorrhage. EGD (esophagogastroduodenoscopy) was performed and revealed hemobilia. A hepatic angiogram was then performed revealing a fistulous tract between a branch of the hepatic artery and biliary tree. Bleeding was successfully stopped by embolization of the bleeding branch of the right hepatic artery. Hemobilia is a rare cause of upper gastrointestinal bleeding with an increasing incidence due to the widespread use of invasive hepatobiliary procedures. Hemobilia is an especially uncommon complication of TIPS procedures. We recommend that in cases of hemobilia after TIPS placement, a physician should immediately evaluate the bleeding to exclude an arterio-biliary fistula.

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Introduction/purposeThe role of endovascular stenting in the setting of traumatic cervical internal carotid artery pseudoaneurysms continues to evolve as its understanding is limited in the medical literature. The purpose of this report is to review the indications, results, and complications associated with endovascular stenting with or without the use of coils for traumatic cervical internal carotid artery pseudoaneurysms at a large level I trauma center.Materials and MethodsA retrospective review was performed on all patients who underwent endovascular stenting for traumatic cervical internal carotid artery pseudoaneurysms from January 1, 2002 through December 31, 2011 at a level I trauma center. Data on the indications for treatment, type and number of stents used with or without metallic coils, immediate angiographic results, and follow-up imaging results and clinical outcomes were gathered and are presented. Follow-up imaging consisted of either CT scanning, ultrasound, and/or digital subtraction angiography between 1 and 84 months post stenting.ResultsA total of 37 cervical internal carotid arteries in 35 patients were stented during this 10-year period. Indications for stenting included enlarging pseudoaneurysms, worsening intraluminal stenoses, and recurrent strokes despite therapeutic antithrombotic medications as well as significant perfusional compromise to the brain. 23 arteries were treated using a single stent while 14 arteries were treated with dual overlapping stents. Seven arteries were treated with coils in addition to stenting. A covered stent was used in one case of dual overlapping stents in which active extravasation was present. Follow-up imaging is available on 27 lesions. 21 of 27 lesions (78%) on follow-up imaging demonstrated no residual vascular abnormalities, 4 (15%) demonstrated mild in-stent narrowing, 1 (4%) demonstrated a residual but improving pseudoaneurysm at 2 years post stenting, and 1 (4%) demonstrated a new, small mid stent pseudoaneurysm. Periprocedural complications were uncommon and included mild, asymptomatic in-stent narrowing in one case and groin hematoma in two cases which resolved without further complication. No procedural related clinical evidence of stroke was encountered.ConclusionEndovascular stenting for the treatment of traumatic cervical internal carotid artery pseudoaneurysms is safe and efficacious. Stenting alone without coils and the use of a single bare metal stent without coils can be used to sufficiently exclude the pseudoaneurysm from the parent artery while maintaining patency of the parent artery. To our knowledge, this is the largest series of endovascular repair of these lesions reported to date. Limitations of this study include its retrospective design and the heterogeneity of the endovascular treatment methods that were used. While these early results are encouraging, long-term data with late follow-up results will be necessary to provide a better understanding of the safety and efficacy of these devices.Competing interestsNone.

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