Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review

Abstract

Patient: Male, 90Final Diagnosis: Ruptured cystic artery pseudoaneurysmSymptoms: Epigastric pain • FeverMedication: —Clinical Procedure: Open cholecystectomySpecialty: Gastroenterology and HepatologyObjective:Rare diseaseBackground:Cystic artery pseudoaneurysm is rare, and some cases are associated with inflammation of the gallbladder. There is limited information regarding this condition, and the clinical features remain unclear. This report is a case of ruptured cystic artery pseudoaneurysm diagnosed by computed tomography (CT) imaging and treated with urgent cholecystectomy and is supported by a literature review of previous cases.Case Report:A 90-year-old man, who had developed acute cholecystitis due to a gallstone one month previously, was referred to our hospital. He developed fever and epigastric pain while waiting for a scheduled elective cholecystectomy. Laboratory investigations showed elevated markers of inflammation and elevated hepatobiliary enzyme levels. Computed tomography (CT) imaging showed cholecystitis and pseudoaneurysm of the cystic artery. The pseudo-aneurysm had ruptured and was accompanied by the formation of a hematoma within the gallbladder that involved the liver bed. Having made the preoperative diagnosis, an urgent open laparotomy was performed, during which the gallbladder was found to have perforated. The hematoma penetrated into the liver bed. Cholecystectomy was performed, and the pseudoaneurysm of the cystic artery was extirpated. There were no serious postoperative complications. A literature review identified 50 previously reported case of cystic artery pseudoaneurysm.Conclusions:A case of ruptured cystic artery pseudoaneurysm, successfully treated with urgent cholecystectomy is reported, supported by a literature review of previous cases and characterization of the clinical features of this rare condition.

Cystic Artery Hemorrhage after Cholecystostomy Catheter Exchange Treated with Transcatheter Embolization

“…2,4 Despite the high incidence of acute and chronic cholecystitis, cystic artery pseudoaneurysms are rarely observed, as the same inflammatory process may also promote vessel thrombosis. 2,3 In the presented case, dual-antiplatelet therapy may have prevented vessel thrombosis allowing for the formation of a pseudoaneurysm and clinically significant hemorrhage.…”

“…Pseudoaneurysms of the cystic artery are an uncommonly reported entity. 2,3,5 Although the pathogenesis of formation of cystic artery aneurysm is not well understood, it is postulated that the inflammatory process associated with cholecystitis results in erosion of the cystic artery wall. 2,4 Despite the high incidence of acute and chronic cholecystitis, cystic artery pseudoaneurysms are rarely observed, as the same inflammatory process may also promote vessel thrombosis.…”

“…Pseudoaneurysms of the cystic artery are an uncommon source of clinically significant hemorrhage. [1][2][3] 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. 2,4 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.…”

Erodes and bleeds, fistulises and obstructs: Bouveret’s syndrome

“…Fujimoto et al. 4 reviewed the largest number of cases of cystic artery pseudoaneurysm with acute cholecystitis: 43/50 (86%) cases had ruptured before diagnosis . Our case of bleeding from a cystic artery pseudoaneurysm may be unique.…”

Vascular disorders of the gallbladder and bile ducts: Imaging findings

“…34 Pathologically there is transmural inflammation of the gallbladder wall with resultant infarction and erosion of the mucosa, which in turn may cause hemorrhage into the gallbladder lumen. 34 In some cases, the inflammation may involve the wall of the cystic artery, 35 resulting in damage to the adventitia with localized weakness in the vessel wall 33 and pseudoaneurysm formation. 36 Fujimoto et al 35 cystic artery pseudoaneurysms secondary to cholecystitis.…”