Fatal bile pulmonary embolism after radiofrequency treatment of a hepatocellular carcinoma

Abstract

Radiofrequency is increasingly used to manage liver tumors. This report describes the case of a 74-year-old man who received two courses of percutaneous radiofrequency thermal ablation for a hepatocellular carcinoma over a 4-month period. He subsequently required computed tomography-guided drainage for an area of intrahepatic necrosis. During the procedure, hemobilia developed, followed by respiratory distress and collapse. The diagnosis of bile pulmonary embolism was established on the basis of high biliary acid concentrations in pulmonary fluid aspiration and blood plasma. Radiofrequency thermoablation provides local control of advanced liver tumors with low recurrence and morbidity. However, this interventional procedure risks damage to liver parenchyma involving vascular and biliary structures, which may lead to biliary-venous fistula and possible bile emboli.

First Report of a Late Lethal Pulmonary Biliary Embolism following Hepatic Microwave Ablation

“…The rapid deterioration did not permit possible therapeutic options like biliary decompression, drainage, or venous stenting. It is noteworthy that the drainage of the collection can itself trigger the complication, as already described in the literature [6]. The autopsy showed, in the microemboli of every embolized pulmonary vessel, mainly bile material (Fig.…”

“…After the first mention of the term bilhemia in 1974 by Clemens and Wittrin [8], the milestone publication of Sandblom et al [7] in 2000 was the first to describe the condition; they reported 50 cases, 23 of which were due to trauma and 14 due to iatrogeny. Since then, in a period of 20 years, around 20 cases of bilhemia have been described [6, 9-24]. Recognized iatrogenic causes are percutaneous transhepatic cholangiography [23], transjugular interventions [12, 18, 20, 22], transhepatic central venous catheter placement [14] and liver punction or drainage [10, 11, 24] including 1 case with an abscess drainage after ablative therapy [6].…”

“…Since then, in a period of 20 years, around 20 cases of bilhemia have been described [6, 9-24]. Recognized iatrogenic causes are percutaneous transhepatic cholangiography [23], transjugular interventions [12, 18, 20, 22], transhepatic central venous catheter placement [14] and liver punction or drainage [10, 11, 24] including 1 case with an abscess drainage after ablative therapy [6]. Other nontraumatic causes include local infectious processes commonly related to lithiasis [9, 13, 21].…”

“…Other nontraumatic causes include local infectious processes commonly related to lithiasis [9, 13, 21]. BPE occurred in 22 of the total 70 reported cases and was always fatal (Table 1) [6-24].…”

“…In the literature, there is only one reported case of biliary pulmonary embolism (BPE) related to ablative therapy in 2003. Schmidt-Mutter observed a BPE that occurred during CT-guided drainage of an intrahepatic fluid collection with abscess characteristics following 2 courses of RFA of a hepatocellular carcinoma [6].…”