• gastrointestinal bleeding
• hepatic artery pseudoaneurysm
• infection
• liver transplantation
• rupture

• Humans
• Hemobilia/etiology
• Hemobilia/diagnosis
• Hemobilia/therapy
• Aneurysm, False
• Liver/injuries
• Jaundice/etiology
• Gastrointestinal Hemorrhage
• Wounds, Nonpenetrating/complications

• Pseudoaneurysm
• thrombin
• transarterial
• trauma

• Male
• Humans
• Young Adult
• Adult
• Thrombin
• Aneurysm, False/diagnostic imaging
• Aneurysm, False/etiology
• Aneurysm, False/therapy
• Treatment Outcome
• Liver
• Embolization, Therapeutic

• advanced breast cancer
• bleeding
• embolization

• Humans
• Female
• Embolization, Therapeutic
• Breast Neoplasms

• Hemobilia
• Hepatic artery pseudoaneurysm
• Hepatic trauma

Hemobilia is a term used to describe bleeding caused by abnormal communication between blood vessels and bile ducts. Some vascular anomalies, such as aneurysms or arterio-biliary fistulas, facilitate the appearance of this type of biliary bleeding. Other causes have been described such as iatrogenic causes secondary to percutaneous procedures, infections, tumors, and trauma. We report two cases of hemobilia. The first one presented with acute biliary bleeding with secondary hypovolemic shock. Bleeding was controlled after percutaneous interventions with a selective embolization technique. The second case was a patient who presented to the emergency department after a fall from his height. During hospitalization, acute cholangitis was documented, associated with hemobilia. A wide papillotomy and biliary duct instrumentation were done with the extraction of a large blood clot. Angiography is the standard for diagnosis and embolization becomes the best tool for the detection and control of vascular abnormalities that can perpetuate bleeding.

Hepatic artery aneurysms (HAA) are rare and it accounts 20% of all visceral artery aneurysms. Commonly HAAs are autopsy findings, but rupture and bleeding carrying significant morbidity and can manifest as haemobilia.

A 63-year-old Sri Lankan male presented with severe melaena upper abdominal pain and features of obstructive jaundice was found to have a giant pseudoaneurysm at the right hepatic artery with the possible arterio-biliary fistula. The etiology for the pseudoaneurysm was not identified. Despite massive transfusion, the patient died before the endovascular intervention.

Atherosclerosis is the leading cause of HAA formation but can be associated with connective tissue disorders and arteritis. Most of the HAA are asymptomatic. Aneurysms can be managed with surgical or endovascular interventions.

Life-threatening haemobilia is a notorious complication of the rapture of HAA into the biliary system. The incidents of hepatic artery aneurysms and pseudoaneurysms due to percutaneous transhepatic interventions and minimal invasive hepatobiliary surgeries are in the rising trend. Nonleaking VAA can be best treated with endovascular treatment. The knowledge on this topic is important for the early detection and intervention of this rare entity.

•

Massive Gastrointestinal bleeding can be haemobilia.

• Aterio-biliary fistula
• Case report
• Endovascular treatment
• Haemobilia
• Hepatic artery aneurysms
• Visceral artery aneurysm

• Embolization
• Endovascular
• Hepatic artery
• Intrahepatic
• Pseudoaneurysm
• Trauma

Visceral artery aneurysms (VAA) are an uncommon but well recognized condition. Hepatic artery aneurysms (HAA) represent 14-20% of all visceral artery aneurysms. Post traumatic hepatic artery pseudoaneurysm is an uncommon delayed complication of blunt liver trauma. Here we present a case of a 27 year old male with blunt abdominal trauma who developed a post traumatic pseudoaneurysm of the hepatic artery just proximal to its bifurcation into the left and right branches. The pseudoaneurysm ruptured within 12 hours of injury and he required double ligation of the hepatic artery as well as right and left hepatic arteries. However, the bleeding continued through the retrograde flow from the gastroduodenal artery and hence, ligation of gastrodudenal artery was also done. The decision of complete devasularisation of liver was taken as an emergency lifesaving procedure. The patient recovered and was discharged without sequel.

• Hepatic artery
• posttraumatic
• pseudoaneurysm

• Capsule endoscopy
• Computed tomography enterography–angiography
• Intra-operative enteroscopy
• Non-variceal gastrointestinal bleed
• Tc99m pertechnetate scan

• bleeding
• imaging
• liver
• management
• masses
• pathologic correlation

Blunt injuries to visceral organs have the potential to lead to delayed pseudoaneurysm formation or organ rupture, but current trauma and surgical guidelines do not recommend repetitive imaging. This study examined the incidence and timing of delayed undesirable events and established advisable timing for follow‐up imaging and appropriate observational admission.

Patients with blunt splenic (S), liver (L), or kidney (K) injury treated with non‐operative management (NOM) in our institution were included and retrospectively reviewed.

From January 2013 to January 2017, 57 patients were admitted with documented blunt visceral organ injuries and 22 patients were excluded. Of 35 patients (L, 10; S, 17; K, 6; L & S, 1; S & K, 1) treated with NOM, 14 (L, 4; S, 9; K, 1) patients underwent transcatheter arterial embolization. Delayed undesirable events occurred in four patients: three patients with splenic pseudoaneurysm on hospital day 6–7 and one patient with splenic delayed rupture on hospital day 7. The second follow‐up computed tomography scan carried out 1–2 days after admission did not show any significant findings that could help predict undesirable results of delayed events. The patients with delayed events had longer continuous abdominal pain than that of event‐free patients (P = 0.04).

Undesirable delayed events were recognized on follow‐up computed tomography scans in 11.4% of NOM patients at hospital day 6–7 and tended to be associated with high‐grade splenic injuries and continuous symptoms. Repetitive screening of these patients 6–7 days after injury might be warranted because of the potential risk of delayed events.

• Blunt trauma
• delayed rupture
• non‐operative management
• pseudoaneurysm

Hepatic artery pseudoaneurysm (HAP) incidence is rising due to more common use of endoscopic and percutaneous hepatic interventions. HAP is potentially fatal, as it could lead to sudden life-threatening hemorrhage. HAP can be intrahepatic or extrahepatic. On computed tomography angiogram (CTA) and magnetic resonance angiogram (MRA), HAP follows blood pool on multiphasic examination, with brisk arterial enhancement that washes out, similar to the abdominal aorta on later phases. We present a case of idiopathic giant HAP in an 82-year-old male. Currently, angioembolization is replacing surgery as the initial modality of choice for management of this condition.

• Bile-duct injury
• Cholecystectomy
• Pseudoaneurysm

• embolization
• hemobilia
• imaging
• interventional radiology

Radiofrequency ablation (RFA) of a hepatic tumour is an established treatment option with an acceptable complication rate. Formation of a pseudoaneurysm after RFA of liver metastasis is an uncommon complication. We report the case of a 69-year-old female patient developing a hepatic pseudoaneurysm after RFA of liver metastasis. On a follow-up CT scan 6 weeks later, there was spontaneous resolution of the pseudoaneurysm. Hepatic pseudoaneurysms are usually treated owing to the risk of rupture. Invasive procedures or conservative management of an asymptomatic hepatic pseudoaneurysm is still the subject of debate. The spontaneous resolution of a hepatic pseudoaneurysm in our patient suggests that an asymptomatic pseudoaneurysm maybe observed for resolution instead of being treated at presentation.

Pseudoaneurysm is a known complication of pancreatitis associated with significant mortality and morbidity. Imaging plays an important role in the diagnosis and management. Computed tomography (CT) helps localize the lesion and the severity of the background pancreatitis but digital subtraction angiography with coil embolization is recommended to avoid bleeding and inadvertent surgery. However, in cases where angiographic coil embolization is not feasible due to technical reasons, thrombin injection via CT or ultrasound guidance remains a viable option and often described in literature. In this series, effort has been made to highlight the role of endoscopic ultrasound guided thrombin instillation especially in patients with poorly visualized pseudoaneurysm on ultrasound thereby avoiding surgery and the associated mortality and morbidity.

• Pseudoaneurysm
• Angiography
• Endoscopic ultrasound
• Thrombin
• Pancreatitis

Posttraumatic pseudoaneurysms (PAs) have been recognized as the cause of delayed hemorrhage complicated with nonoperative management (NOM), although the need for intervention in patients with small-sized PAs and the relationship between the occurrence of PAs and bed-rest has been also unclear.

The purpose of this study was to investigate the clinical history of small-sized PAs (less than 10 mm in diameter) which occurred in abdominal solid organs, and to analyze the relationship between the occurrence of PAs and early mobilization from bed.

Sixty-two patients who were successfully managed with NOM were investigated. Mobilization within three days post-injury was defined as “early mobilization” and bed-rest lasting over three days was defined as “late mobilization.” A comparison of the clinical factors, including the duration of bed-rest between patients with and without PAs detected by follow-up CT was performed. Furthermore, a multiple logistic regression model analysis on the occurrence of PAs was performed.

PAs were detected in 7 of the 62 patients. The One patient with PAs measuring larger than 10 mm received trans-arterial embolization, and the remaining six patients with PAs smaller than 10 mm were managed conservatively. Consequently, no delayed hemorrhage occurred, and the PAs spontaneously disappeared in all of the six patients managed without intervention. The multiple regression model analysis revealed that early mobilization was not a significant factor predicting new-onset PAs.

Small PAs can be expected to disappear spontaneously. Moreover, early mobilization is not a significant risk factor for the occurrence of PAs.

• Abdominal Injuries/complications
• Abdominal Injuries/pathology
• Abdominal Injuries/therapy
• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Aneurysm, False/etiology
• Aneurysm, False/pathology
• Aneurysm, False/therapy
• Female
• Humans
• Male
• Middle Aged
• Wounds, Nonpenetrating/complications
• Wounds, Nonpenetrating/pathology
• Wounds, Nonpenetrating/therapy

Objective. To evaluate the technical success, safety, and outcome of endovascular embolization procedure in management of visceral artery pseudoaneurysms. Materials and Methods. 46 patients were treated for 53 visceral pseudoaneurysms at our institution. Preliminary diagnostic workup in all cases was performed by contrast enhanced abdominal CT scan and/or duplex ultrasound. In all patients, embolization was performed as per the standard departmental protocol. For data collection, medical records and radiology reports of all patients were retrospectively reviewed. Technical success, safety, and outcome of the procedure were analyzed. Results. Out of 46 patients, 13 were females and 33 were males. Mean patient age was 44.79 ± 13.9 years and mean pseudoaneurysm size was 35 ± 19.5 mm. Technical success rate for endovascular visceral pseudoaneurysm coiling was 93.47% (n = 43). Complication rate was 6.52% (n = 3). Followup was done for a mean duration of 21 ± 1.6 months (0.5–69 months). Complete resolution of symptoms or improvement in clinical condition was seen in 36 patients (80%) out of those 45 in whom procedure was technically successful. Conclusion. Results of embolization of visceral artery pseudoaneurysms with coils at our center showed high success rate and good short term outcome.

Hepatic artery pseudoaneurysms (HAP) are rare events, particularly after liver biopsy, but can be associated with serious complications. Therefore a high suspicion is necessary for timely diagnosis and appropriate treatment. We report on a case of HAP that potentially formed after a liver biopsy in a patient with sarcoidosis. The HAP in our case was virtually undetectable initially by angiography but resulted in several complications including recurrent gastrointestinal bleeding, hemorrhagic cholecystitis and finally hepatic infarction with abscess formation until it became detectable at a size of 5-mm. The patient remains asymptomatic over a year after endovascular embolization of the HAP. In this report, we demonstrate that a small HAP can avoid detection by angiography at an early stage while being symptomatic for a prolonged course. A high clinical suspicion with a close clinical/radiological follow-up is needed in symptomatic patients with history of liver biopsy despite initial negative work up. Once diagnosed, HAP can be safely and effectively treated by endovascular embolization.

• Gastrointestinal bleed
• Abnormal liver enzymes
• Hepatic artery pseudoaneurysms
• Liver biopsy
• Angiography

• Abdominal Pain
• Adult
• Aneurysm, False/etiology
• Angiography
• Biopsy/adverse effects
• Cholecystitis/physiopathology
• Embolization, Therapeutic/methods
• Female
• Gastrointestinal Hemorrhage/diagnosis
• Hepatic Artery/pathology
• Humans
• Infarction/complications
• Liver/pathology
• Liver Diseases/complications
• Sarcoidosis/complications
• Sarcoidosis/pathology

• Complication
• Embolization
• Hepatic angiography
• Hepatocellular carcinoma
• Radiofrequency ablation

• Abdominal Injuries/complications
• Abdominal Injuries/surgery
• Aneurysm, False/diagnosis
• Aneurysm, False/etiology
• Aneurysm, False/surgery
• Child
• Diagnosis, Differential
• Hepatic Artery/diagnostic imaging
• Hepatic Artery/surgery
• Humans
• Male
• Radiography
• Treatment Outcome
• Wounds, Nonpenetrating/complications
• Wounds, Nonpenetrating/diagnosis
• Wounds, Nonpenetrating/surgery

• Embolization
• Hemorrhage
• Pancreatitis
• Pseudoaneurysm
• Stenting
• Vascular complications