AJR 2001; 177:819-821
© American Roentgen Ray Society
Intrahepatic Pseudoaneurysm Complicating Transjugular Biopsy of the Liver
C. J. Roche1,
W. K. Lee,
V. A. Duddalwar,
S. Nicolaou,
P. L. Munk and
D. C. Morris
1
All authors: Department of Radiology, Vancouver General Hospital, 855 W. 12th
Ave., Vancouver, B.C. V5Z 1M9, Canada.
Received February 26, 2001;
accepted after revision April 17, 2001.
Address correspondence to C. J. Roche.
Introduction
Transjugular biopsy of the liver is generally considered a useful technique
for obtaining tissue specimens when coagulopathy or gross ascites
contraindicates percutaneous biopsy. Many large studies have shown that
transjugular biopsy of the liver is a safe technique, with reported
complication rates of 0-20%
[1,2,3,4,5].
To our knowledge, intrahepatic arterial pseudoaneurysm has not been previously
reported as a complication of this technique.
Case Report 1
A 48-year-old woman had a bone marrow transplantation for low-grade
non-Hodgkin's lymphoma. The patient's recovery after transplantation was
complicated by severe graft-versus-host disease (GVHD) affecting her liver,
skin, lungs, and gastrointestinal tract. Six months after bone marrow
transplantation, she underwent transjugular biopsy of the liver to investigate
persistently abnormal liver function. The transjugular route was favored
because of thrombocytopenia and an abnormal coagulation profile. Several
specimens of liver tissue were obtained via the right hepatic vein using an
internal jugular approach and a spring-loaded liver biopsy needle (LABS-100;
Cook, Bloomington, IN). No immediate complications occurred after the
procedure. Histology confirmed marked GVHD. During the week after undergoing
transjugular biopsy of the liver, the patient passed melanotic stools, and her
hemoglobin dropped by 1 g/dL. This gastrointestinal bleeding was attributed to
GVHD and resolved spontaneously.
One month after transjugular biopsy of the liver, abdominal sonography was
performed to investigate symptoms of right upper quadrant pain. The scan
showed a 4.5-cm round anechoic structure in segment VI of the liver
(Fig. 1A). Color Doppler
sonography showed a swirling pattern of blood flow in this lesion (which
appears as a "yin—yang" sign
[Fig. 1B]), characteristic of a
pseudoaneurysm. On spectral Doppler sonography, the neck of the pseudoaneurysm
showed a to-and-fro arterial flow pattern, and the center showed turbulent
low-resistance arterial flow. The patient underwent selective hepatic
arteriography the next day that showed a large pseudoaneurysm arising from an
inferior branch of the right hepatic artery
(Fig. 1C). The pseudoaneurysm
was embolized with platinum microcoils of 2 and 3 mm in diameter (Complex
Helical Fibered Platinum Coil-18; Target Vascular, Fremont, CA) followed by
small gelatin foam torpedoes (Gel-foam; Pharmacia & Upjohn, Mississauga,
Ontario, Canada) (Fig. 1D).
Sonography performed 2 days later confirmed that the aneurysm was
occluded.
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Fig. 1A. —48-year-old woman with graft-versus-host disease after
undergoing bone marrow transplantation for low-grade non-Hodgkin's lymphoma.
Sonogram of liver shows 4.5-cm anechoic structure in segment VI. Note
posterior acoustic enhancement.
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Fig. 1B. —48-year-old woman with graft-versus-host disease after
undergoing bone marrow transplantation for low-grade non-Hodgkin's lymphoma.
Color Doppler sonogram shows "yin-yang" sign of turbulent flow in
pseudoaneurysm sac.
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Fig. 1C. —48-year-old woman with graft-versus-host disease after
undergoing bone marrow transplantation for low-grade non-Hodgkin's lymphoma.
Selective hepatic arteriogram shows jet of contrast material filling
pseudoaneurysm arising from inferior branch of right hepatic artery.
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Fig. 1D. —48-year-old woman with graft-versus-host disease after
undergoing bone marrow transplantation for low-grade non-Hodgkin's lymphoma.
Postembolization hepatic arteriogram shows that neck of pseudoaneurysm is
occluded.
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Case Report 2
Similar findings were seen in another patient who developed a
pseudoaneurysm after transjugular biopsy of the liver (Fig.
2A,2B).
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Fig. 2A. —50-year-old woman with graft-versus-host disease after bone
marrow transplantation for chronic myeloid leukemia. Transjugular biopsy of
liver was performed to investigate abnormal liver function. One month later,
abdominal sonogram showed 3.6-cm hepatic pseudoaneurysm. Selective hepatic
arteriogram and embolization of pseudoaneurysm using platinum microcoils
(Complex Helical Fibered Platinum Coil-18; Target Vascular, Fremont, CA) was
successfully undertaken. Color Doppler sonogram shows 3.6-cm pseudoaneurysm in
subcapsular location in segment VI of liver. Central portion of pseudoaneurysm
sac contained mobile thrombus.
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Fig. 2B. —50-year-old woman with graft-versus-host disease after bone
marrow transplantation for chronic myeloid leukemia. Transjugular biopsy of
liver was performed to investigate abnormal liver function. One month later,
abdominal sonogram showed 3.6-cm hepatic pseudoaneurysm. Selective hepatic
arteriogram and embolization of pseudoaneurysm using platinum microcoils
(Complex Helical Fibered Platinum Coil-18; Target Vascular, Fremont, CA) was
successfully undertaken. Selective hepatic arteriogram shows pseudoaneurysm
arising from inferior branch of right hepatic artery.
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Discussion
Hepatic arterial pseudoaneurysms have been reported to complicate 0.3-2.1%
[6] of liver transplantation
and usually occur at the anatomosis between the native and donor hepatic
arteries. Hepatic arterial pseudoaneurysms are reported to complicate 0.6% of
laparoscopic cholecystectomies. Intrahepatic arterial pseudoaneurysms are
reported after trauma, percutaneous liver biopsy, percutaneous biliary
drainage, transjugular intrahepatic portosystemic shunt procedures
[7,
8], endoscopic retrograde
cholangiopancreatography, thoracentesis, and amoebic abscess. Pseudoaneurysm
formation is probably more likely to occur when only one side of the arterial
wall is injured. Complete transection of an artery usually does not result in
pseudoaneurysm formation because the vessel retracts as a result of elastic
recoil.
Although pseudoaneurysms are often clinically silent, they are at risk of
rupture, resulting in life-threatening hemorrhage. Hepatic arterial
pseudoaneurysms, whether intra- or extrahepatic, are potentially
life-threatening because they can rupture into the hepatic or portal venous
system, the biliary tree (resulting in hemobilia), or the peritoneum.
Transjugular biopsy of the liver is a safe technique for obtaining adequate
liver tissue in certain clinical situations. The indications for using a
transjugular approach instead of a percutaneous approach include the
following: massive ascites, noncorrectable coagulation disorder, the need to
measure hepatic or vena caval pressure, and suspected vascular tumor or
peliosis hepatis [1,
2]. A transjugular approach is
also technically easier to perform and is safer than a transfemoral approach,
which uses endocardial biopsy forceps. Diagnostic samples are obtained in
77-97% [1,
2,
5] of transjugular liver
biopsies. Reported complication rates for transjugular biopsy of the liver are
0-20%
[1,2,3,4,5].
To our knowledge, intrahepatic pseudoaneurysm has not been reported as a
complication of this technique.
It is possible that pseudoaneurysms are more common after biopsy because
they are often clinically silent. Many pseudoaneurysms presumably thrombose
spontaneously. The fact that both patients in this case study had severe
underlying GVHD of the liver may indicate that they were at increased risk for
a pseudoaneurysm as a result of the transjugular approach. In both patients,
gastrointestinal bleeding, manifested as melena, occurred during the period
immediately after the biopsy. Although other causes (including intestinal GVHD
in both patients and a peptic ulcer in the second patient) may have accounted
for this bleeding, the temporal relationship to transjugular biopsy of the
liver raises the possibility that the bleeding may have been caused by
hemobilia, a common accompaniment of intrahepatic pseudoaneurysms.
Transcatheter embolization of hepatic pseudoaneurysms is an effective
method of treatment. However, if transcatheter embolization is not feasible
because of adverse arterial anatomy or contraindication to IV contrast
material, a percutaneous injection of thrombin into the pseudoaneurysm sac
with sonographic or CT guidance can be used as an alternative approach.
Because intrahepatic pseudoaneurysms may be asymptomatic, a high index of
suspicion should be maintained. An apparently cystic or hypoechoic structure
in the liver or at the hepatic hilum in a patient with a history of prior
liver biopsy or transplantation should not be dismissed as a simple cyst,
seroma, or infected collection unless Doppler imaging excludes flow.
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Introduction
Case Report 1
