External Tamponade of Pseudoaneurysm

Purpose: This case provides an example of a patient who developed hemobilia after placement of a percutaneous biliary catheter. Because of the patient’s reduced liver reserve, embolization was not a feasible option, and a different technique was used to remedy the problem. This unconventional approach involved placing a balloon into the biliary tree to tamponade the bleed.

Materials and Methods: A 54-year-old man with a large hepatic neuroendocrine tumor underwent extended right hepatectomy, wedge resections, ablations, and biliary reconstruction. This was complicated postoperatively by esophageal and duodenal ischemia related to COVID-19 coagulopathy, subsequently requiring a total gastrectomy, partial duodenal resection, and delayed reconstruction. His treatment included placement of percutaneous biliary catheters into the left medial and lateral bile ducts. During his recovery, he presented with bright red blood in the left biliary catheter drain bag and hemoglobin drop from 10.1 to 6.8 g/L over 6 hours. Interventional radiology was then consulted to perform a cholangiogram, angiogram, and possible embolization.

Over-the-wire cholangiogram was performed demonstrating clot within the left biliary tree. A hepatic angiogram was performed demonstrating a pseudoaneurysm (PSA) with active extravasation into the left biliary tree, and a 2.8 Progreat microcatheter (Terumo Medical Corporation) was used to subselect the segment four branches that gave rise to the PSA.

Results: Because of the patient’s diminished liver reserve, the surgeon specifically requested no regional embolization, and the decision was made to externally tamponade the PSA with a 32-mm/120-cm CODA balloon (Cook Incorporated) placed into the left biliary tree through the catheter site. Completion angiogram demonstrated persistent PSA without extravasation.

Over the course of the next 3 days, the patient required no additional transfusions; however, on postoperative day 2, the patient spiked a low-grade fever, and the balloon was removed on postoperative day 3 and has been without incident on 1 month follow-up.

Conclusions: Intrahepatic arterial damage can cause significant harm and possibly loss of life. Being aware of clinical signs and use of unique ways to treat the problem is crucial stabilize the patient.