Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

Abstract

Pseudoaneurysms (PSAs) of the hepatic and/or cystic artery are a rare complication following a laparoscopic cholecystectomy (LC). Generally, PSA cases present with haemobilia several weeks following the procedure. Transarterial embolisation (TAE) is considered the optimal management approach. We report a 70-year-old woman who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with massive hemoperitoneum two weeks after undergoing a LC procedure in another hospital. She was successfully managed using coil TAE. An extensive literature review revealed 101 cases of hepatic or cystic artery PSAs following a LC procedure. Haemobilia was the main presentation (85.1%) and the mean time of postoperative presentation was 36 days. The hepatic artery was involved in most cases (88.1%), followed by the cystic artery (7.9%) and a combination of both (4.0%). Most cases were managed with TAE (72.3%), with a 94.5% success rate. The overall mortality rate was 2.0%.

Cystic Artery Variations and Associated Vascular Complications in Laparoscopic Cholecystectomy

“…In 82% of scenarios, embolization was documented typically effective while, surgical procedures needed in remainder 18% of the subjects [36]. When coils are utilized, they are able to the originator of thrombosis; consequently, in sufferers with considerable coagulopathies, the blood vessel might still continue to be distinct regardless of embolization plus the course of action could possibly be inadequate to managing blood loss [72]. In modest PSAs, glue works extremely well as an alternative because the adhesive contours towards the type of PSA [73].…”

“…In the event wherein the PSA continues to be expanded following preliminary management with TAE, following operative management had been documented by which an exploratory laparotomy and ligation of the nourishing vessel ended in an entire recuperation [57]. Excision helps to ensure that a PSA won't expand resulting from continual arterial blood pressure; furthermore, failing to excise the PSA may bring about its burst because the aneurysm is frequently contaminated [72]. A number of people who typical to hemobilia and obstructive jaundice may additionally need endoscopic retrograde cholangiopancreatography and transhepatic biliary drainage while in some circumstances CBD exploration to vacate the blood clot in the event the jaundice won't get better [49,52].…”

Elderly man with abdominal and chest pain

“…Pseudoaneurysm formation of the cystic or hepatic arteries is a rare but well‐described complication of laparoscopic cholecystectomy 1 . Predisposing factors include inadvertent mechanical injury to the arteries during surgery, excessive or inappropriate use of thermal cauterization, and leakage of bile due to inadvertent injury to the biliary tree 2 . Pseudoaneurysms will appear as a cystic fluid collection on grey scale ultrasound; however, interrogation with color flow Doppler will reveal the characteristic “yin‐yang” sign that is created from the in‐and‐out turbulent blood flow pattern 3 .…”

“…Pseudoaneurysms will appear as a cystic fluid collection on grey scale ultrasound; however, interrogation with color flow Doppler will reveal the characteristic “yin‐yang” sign that is created from the in‐and‐out turbulent blood flow pattern 3 . Emergent CT angiography with trans‐arterial embolization remains the gold standard for imaging and treatment of visceral artery pseudoaneurysms 2 …”

Idiopathic Giant Hepatic Artery Pseudoaneurysm

“…Visceral artery aneurysms are uncommon, with an incidence of 0.1% to 10.0% in autopsy series [ 2 ]. HAP is a rare complication of liver trauma and liver transplant [ 3 , 4 ]. Hepatic artery aneurysms incidence is estimated at 0.002%, and approximately 50% of hepatic artery aneurysms are pseudoaneurysms [ 5 ].…”