Utility of Stent-Grafts in Treatment of Porto-Biliary Fistula

Abstract

A porto-biliary fistula causing hemobilia is a known complication of percutaneous transhepatic biliary drainage (PTBD). We present two patients with hemobilia secondary to porto-biliary fistula, treated successfully by percutaneous placement of stent-grafts. In one case, the stent-graft was placed in the bile duct, and in the other case, it was placed in the intrahepatic portal vein branch. Hemobilia stopped and there were no complications except a small area of hepatic infarction, distal to the stent-graft in the portal vein.

Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement

“…The risks of covered stent placement in biliary system include isolation of other nondrained ducts, which may cause cholangitis, occlusion of pancreatic duct which may cause pancreatitis and stent migration. 10,13 In our patient, the PTBD catheter was draining only ducts of segments 2 and 3 as the disease had already involved primary and bilobar secondary biliary confluence and hence there was no increase in risk of ductal isolation. This was confirmed by doing ultrasonography 3 days after stent placement.…”

“…10 All these three options were discussed in our case. Portal vein stenting and portal vein embolization would need gaining access to the vein and placing the stent, which would delay hemostasis.…”

“…6,7 In patients with biliary malignancy, biliovenous fistula may develop as a result of catheter or biliary stent eroding into the portal vein or by tumor invasion. 10 When there is such vascular communication, radiological intervention becomes necessary. The type of intervention depends on the severity of hemorrhage.…”

“…Further, there is a risk of liver infarct with portal vein embolization as the status of left hepatic artery was not known. 10 Coil embolization of the fistulous tract was difficult as the fistula was very short in length and not well localized. Since the patient had deranged coagulation parameters and the communication with the left portal vein was closer to the bifurcation, biliary stent placement was decided as the optimal treatment.…”

“…6,7 Biliovenous fistula is a rare complication, seen in less than 0.5% cases, with few cases reported in literature. 4,[8][9][10][11][12] These cases are either managed conservatively or by radiological interventions in the form of balloon occlusion, coiling or covered stent placement depending on patient's hemodynamic status. 4,[8][9][10][11] We report a case of 56-year-old male with carcinoma of gall bladder, who developed bilio-venous fistula 3 weeks after PTBD and presented with features of hemodynamic shock and was managed by placement of biliary covered stent.…”