Cystic Artery Hemorrhage after Cholecystostomy Catheter Exchange Treated with Transcatheter Embolization

Abstract

The pathogenesis of formation of cystic artery pseudoaneurysms is not well understood, but is thought to result from erosion of the cystic artery wall from the adjacent inflammatory process associated with acute or chronic cholecystitis. The presented case discusses an incident of hemorrhage from a cystic artery pseudoaneurysm resulting in a large perihepatic hematoma as well as hemobilia, which developed after a routine cholecystostomy catheter exchange. This was treated with transcatheter embolization using ethylene-vinyl alcohol copolymer.

Beware of Rattling Underfoot: Cystic Artery Pseudoaneurysm in Acute Cholecystitis With a Cholecystostomy

“…As the patient was on dual antiplatelet therapy following their cardiac surgery, cholecystectomy was deferred, and a cholecystostomy catheter was placed to drain their gallbladder. The cholecystostomy catheter had been in situ for four months before CAP was detected [2]. The authors hypothesise that dual antiplatelet therapy contributed to the development of CAP in this case by preventing the thrombosis which would be expected to occur in the cystic vessels in response to inflammation.…”

“…Cystic artery pseudoaneurysms (CAP) are rare and have been reported to occur as a complication of acute cholecystitis when CAP formation is likely to result from damage to the vessel wall caused by the inflammatory process [1]. There are also reports of CAP following cholecystectomy, where traumatic injury of the cystic artery leads to the subsequent development of CAP [2]. CAP can present as haemobilia, jaundice, right upper abdominal pain, and fever [3].…”

Transcatheter arterial embolization of cystic artery bleeding

“…Several studies involving patients with gastrointestinal bleeding, hemoptysis, post-partum bleeding, and musculoskeletal bleeding have reported favorable outcomes with respect to the safety and effectiveness of TAE (1)(2)(3)(4)(5). Bleeding originating from the cystic artery may be associated with surgical cholecystectomy, hemorrhagic cholecystitis, gallbladder cancer, and prior percutaneous drainage of the gallbladder (6)(7)(8)(9). Several case studies have documented the successful use of TAE in treating cystic artery bleeding (6)(7)(8)(9), and embolization procedures through the cystic artery have been safely attempted for the management of hepatocellular carcinoma (10)(11)(12).…”

“…Bleeding originating from the cystic artery may be associated with surgical cholecystectomy, hemorrhagic cholecystitis, gallbladder cancer, and prior percutaneous drainage of the gallbladder (6)(7)(8)(9). Several case studies have documented the successful use of TAE in treating cystic artery bleeding (6)(7)(8)(9), and embolization procedures through the cystic artery have been safely attempted for the management of hepatocellular carcinoma (10)(11)(12).…”