https://orcid.org/0009-0007-3693-3362
Abstract
Bile duct injuries (BDI) after cholecystectomy often coexist with vascular injuries, but hepatic artery pseudoaneurysms may be missed on initial imaging. We report a right hepatic artery (RHA) pseudoaneurysm that manifested as haemobilia only after biliary decompression by Roux-en-Y hepaticojejunostomy for a Strasberg type E3 injury. A 28-year-old man presented 4 weeks after open cholecystectomy with obstructive jaundice. Magnetic resonance imaging confirmed a Strasberg type E3 stricture and identified a missed 8-mm RHA pseudoaneurysm. Following hepaticojejunostomy, haematemesis occurred on postoperative day 3. Computed tomography angiography demonstrated enlargement of the pseudoaneurysm to 12-mm with arteriobiliary communication. Covered stenting was followed by recurrent bleeding requiring glue–lipiodol embolization, complicated by non-target splenic embolization and an abscess requiring percutaneous drainage. The patient recovered and remained asymptomatic at three months. This case suggests that relief of biliary hypertension can unmask contained pseudoaneurysms and reinforces the importance of routine preoperative arterial-phase imaging in complex BDI.
Introduction
Bile duct injuries (BDI) are among the most serious complications of cholecystectomy and are frequently associated with concomitant vascular injuries, particularly to the right hepatic artery (RHA), owing to the close anatomical relationship in Calot’s triangle [1, 2]. These vasculobiliary injuries often present with predominant biliary symptoms, allowing vascular complications to go unrecognized during initial assessment [3]. Hepatic artery pseudoaneurysms may remain clinically silent during biliary obstruction, possibly due to a tamponading effect of elevated intraductal pressure [4]. Relief of biliary hypertension can permit expansion and fistulization of a pre-existing pseudoaneurysm into the biliary tree, resulting in haemobilia [5]. We report a RHA pseudoaneurysm that manifested as haemobilia only after Roux-en-Y hepaticojejunostomy (HJ) for a Strasberg type E3 BDI. The case illustrates how biliary decompression can unmask contained pseudoaneurysms and highlights technical considerations in endovascular management.
Case report
A 28-year-old man presented 4 weeks after open cholecystectomy with progressive obstructive jaundice and right upper quadrant pain. There was no prior gastrointestinal bleeding. Laboratory findings showed total bilirubin 21.98 mg/dl and markedly elevated alkaline phosphatase. Contrast-enhanced magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) demonstrated a high hilar biliary stricture with complete occlusion immediately distal to the confluence and marked intrahepatic duct dilatation, consistent with a Strasberg type E3 BDI (Fig. 1). Retrospective review identified an overlooked 8 mm saccular pseudoaneurysm arising from the mid RHA (Fig. 1B). Preoperative computed tomography angiography (CTA) was not performed as the presentation was dominated by obstructive jaundice and MRCP adequately delineated biliary anatomy; arterial-phase imaging was not routine at our institution for benign strictures.
Preoperative contrast-enhanced MRI of the abdomen with MRCP. (A) Axial image demonstrating a Strasberg type E3 high hilar biliary stricture with marked dilatation of the intrahepatic biliary ducts (asterisk) proximal to the confluence. (B) Axial image showing an 8 mm saccular pseudoaneurysm (asterisk) arising from the mid RHA, which was overlooked on initial reporting and identified only on retrospective review. (C) Three-dimensional reconstructed MRCP image showing a Strasberg type E3 stricture with proximal biliary dilatation and an intact hilar confluence.
The patient underwent elective open Roux-en-Y HJ. Dense adhesions were encountered, but a tension-free wide anastomosis was constructed to the hilar confluence using interrupted polydioxanone sutures (Fig. 2). The postoperative course was uneventful until postoperative day (POD) 3, when he developed two episodes of haematemesis; haemoglobin fell from 12.4 to 7.2 g/dl. On POD 4 he experienced syncope with a further decline to 5.8 g/dl. Oesophagogastroduodenoscopy (OGD) showed fresh blood without an identifiable source. CTA demonstrated enlargement of the pseudoaneurysm to 1.2 cm with features suggestive of arteriobiliary communication (Fig. 3). Urgent endovascular intervention via femoral access deployed a 6 × 40 mm covered stent across the pseudoaneurysm (Fig. 4). A covered stent was chosen over primary embolization to preserve antegrade hepatic arterial flow and minimize ischaemic risk to the fresh HJ. Post-stent angiography confirmed exclusion with preserved distal flow. The timeline of key events is summarized in Table 1.
Intraoperative photograph of the completed Roux-en-Y HJ. A wide, tension-free anastomosis has been constructed between the hepatic duct confluence and the roux limb using interrupted sutures.
Postoperative CTA showing interval enlargement of the RHA pseudoaneurysm with features suggestive of arteriobiliary communication. (A) Axial view. (B) Coronal view (arrow indicates the pseudoaneurysm).
Endovascular management of the RHA pseudoaneurysm. (A) Pre-intervention digital subtraction angiography demonstrating the pseudoaneurysm (arrow). (B) Post-procedure angiogram after deployment of a 6 × 40 mm covered stent (arrow) across the pseudoaneurysm, confirming complete exclusion with preserved distal hepatic arterial flow.
Timeline of clinical events and management
| Time point | Key event | Management / Outcome |
|---|---|---|
| 4 weeks after cholecystectomy | Presentation with obstructive jaundice | MRCP: Strasberg type E3 stricture; 8-mm RHA pseudoaneurysm missed on initial reporting |
| Day 0 | Open Roux-en-Y HJ | Uneventful; oral feeds started on POD 1 |
| POD 3–4 | Haematemesis and syncope; haemoglobi fell to 5.8 g/dl | Negative OGD; CTA showed enlarging RHA pseudoaneurysm with features of arteriobiliary communication |
| POD 4 | Covered stent placement (6 × 40 mm) | Complete exclusion of pseudoaneurysm; haemoglobin improved to 8.9 g/dl |
| POD 10 | Recurrent bleeding | Glue–lipiodol embolization; non-target splenic artery embolization with focal infarcts |
| POD 10–15 | Haemodynamic instability | ICU care and blood transfusions; discharged on POD 15 in stable condition |
| 1 month | Splenic abscess | Percutaneous drainage (200 ml); resolved |
| 3 months | Outpatient follow-up | Asymptomatic with no recurrent bleeding |
ICU, Intensive care unit.
On POD 10, the patient developed recurrent bleeding. Repeat angiography revealed an endoleak with refilling of the pseudoaneurysm. Definitive embolization was performed using a 30% n-butyl cyanoacrylate–Lipiodol mixture (1:3) delivered via selective microcatheter. Complete occlusion was achieved, but non-target splenic artery embolization occurred, resulting in focal splenic infarcts (Fig. 5). The patient developed transient transaminitis, required transfusion support, and was discharged on POD 15. One month later he was readmitted with a splenic abscess, successfully managed by percutaneous drainage. He remained asymptomatic with no recurrent bleeding at 3-month follow-up.
Management of recurrent bleeding after covered stent placement in the RHA pseudoaneurysm. (A) Follow-up digital subtraction angiography demonstrating recurrent filling of the pseudoaneurysm (yellow arrow) with the covered stent in place. (B) Post-embolization digital subtraction angiography confirming complete occlusion of the pseudoaneurysm (yellow arrow) following glue–lipiodol embolization. (C) Computed tomography the day after embolization showing hyperdense embolic material in the RHA (yellow arrow) along with non-target embolization into the splenic artery (red arrow).
Discussion
Vasculobiliary injuries complicate a substantial proportion of major BDI, with RHA involvement reported in up to 47% of patients undergoing repair of post-cholecystectomy strictures [2, 6]. The intimate anatomical relationship between the cystic duct, common hepatic duct and RHA renders the artery susceptible to iatrogenic injury during cholecystectomy [7].
In this case, the pseudoaneurysm likely originated during the index cholecystectomy and remained silent during biliary obstruction. Serial imaging demonstrated clear interval enlargement from 8 mm preoperatively to 1.2 cm after decompression, temporally associated with haemobilia on POD 3 and the absence of bleeding during the preceding four weeks of obstruction [8]. While local inflammation or natural progression cannot be excluded, the precise timing and documented expansion strongly support relief of biliary hypertension as the dominant unmasking mechanism [4, 5]. Upper gastrointestinal bleeding after HJ with a negative OGD should prompt immediate vascular imaging rather than repeated endoscopic attempts [9].
Endovascular management is now first-line for hepatic artery pseudoaneurysms in the early postoperative period [10]. Initial covered stent placement achieved temporary exclusion while preserving hepatic arterial flow; however, endoleak necessitated secondary embolization with n-butyl cyanoacrylate–Lipiodol [11]. Although effective, liquid embolics carry a recognised risk of non-target embolization through reflux, particularly near the coeliac axis [12]. In this case, splenic artery embolization led to infarction and delayed abscess formation, successfully treated by percutaneous drainage [13]. This highlights the importance of superselective access, controlled injection technique, and awareness of altered flow dynamics after stenting [12].
This case reinforces several practical lessons. Routine preoperative arterial-phase imaging (CTA or magnetic resonance angiography) should be considered in all Strasberg type E3–E5 BDI, as subtle pseudoaneurysms are easily missed on standard biliary-focused MRCP [6]. Biliary decompression can unmask contained pseudoaneurysms by eliminating the tamponading effect of elevated intraductal pressure [4, 5]. Endovascular interventions are highly effective but require meticulous techniques to minimize non-target embolization when liquid agents are used [12]. A multidisciplinary approach involving hepatobiliary surgery and interventional radiology enables favourable outcomes even after major haemorrhage and embolization-related complications [14].
To our knowledge, this is one of the few reported cases with serial imaging documentation of interval pseudoaneurysm enlargement temporally linked to surgical biliary decompression. This case also provides practical technical insights into the use of liquid embolics near the coeliac axis. Limitations include the retrospective single-case design, absence of preoperative CTA, relatively short follow-up, and inferential nature of the proposed mechanism. Longer-term surveillance continues for delayed vascular or anastomotic complications.
In conclusion, this case illustrates how biliary decompression can unmask a previously contained RHA pseudoaneurysm, resulting in haemobilia. It underscores the importance of preoperative vascular assessment in complex biliary reconstructions and the need for prompt vascular imaging when gastrointestinal bleeding occurs after hepaticojejunostomy. Staged endovascular management, combined with vigilant postoperative care, achieved a successful outcome despite significant complications.
Author contributions
K.K.: data collection and manuscript writing. M.G.: data collection and imaging interpretation. O.K.S.: data interpretation. A.G.: data collection. T.S.: manuscript writing and editing. A.G. and T.S. performed clinical management and data collection. K.K. drafted the manuscript. M.G., O.K.S., and T.S. revised the manuscript critically. All authors approved the final version.
Conflicts of interest
The authors declare that they have no conflict of interest.
Funding
None declared.
Data availability
The clinical data and images supporting the findings of this case report are included within the article. Additional de-identified data are available from the corresponding author upon reasonable request.
