Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation

Abstract

BackgroundRight hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 – 61% of cases when routine angiography is employed following a BDI.We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI.Case presentationA 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed.Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils.Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully.ConclusionObstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.

Ascending Cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report

“…To our knowledge, this is the first case to be published in the English literature. Some cases of cholangitis after coil embolization of hepatic arteries were reported [17–19]. The best management of these conditions is through ERCP, especially in severe cholangitis like in our case.…”

Biliary obstruction necessitating choledochojejunostomy as a complication of endovascular coil erosion

“…Although coil migration resulting in biliary obstruction has been previously reported, most of these cases involved coils placed in the right hepatic artery in the setting of pseudoaneurysm formation related to complications from cholecystectomy, liver transplantation [11] , [12] , [13] , or percutaneous placement of an internal or external biliary drain [14] . In these cases, the migrated coils causing biliary obstruction were removed percutaneously from the CBD [14] , surgically with a biliary-enteric revision [12] , and endoscopically with a papillary balloon dilation and extraction of coils [13] .…”

Coils migrate into the biliary-jejunum anastomosis

“…When coils migrate into biliary tracts, symptoms of biliary obstruction always develop, such as obstructive jaundice, cholangitis, stones, and pancreatitis. [4,6,7] Experience in dealing with this complication is little. Many doctors do not recognize this rare complication and related symptoms, which results in difficult diagnosis and management.…”