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AJR Integrative Imaging LIFELONG LEARNING FOR RADIOLOGY |
1 Department of Vascular and Interventional Radiology, University of Chicago
Hospitals, MC-2026, 5841 S Maryland Ave., Chicago, IL 60637.
2 Department of Radiology, Weiss Memorial Hospital, Chicago, IL.
Received May 19, 2007; accepted after revision June 11, 2007.
Address correspondence to S. Regalado
(sidreg3{at}yahoo.com).
Keywords: cholecystectomy • complication • embolization • hemorrhage
OBJECTIVE
The diagnosis and management of postoperative symptomatic intraperitoneal hemorrhage and hemobilia that occurred after an open cholecystectomy and common bile duct exploration for symptomatic choledocholithiasis are discussed. An active bleeding source from the cystic artery stump was identified by angiography. Minimally invasive therapeutic options, including arterial embolization, are addressed.
CONCLUSION
Postoperative intraperitoneal hemorrhage and hemobilia of a cystic artery stump can be accurately diagnosed and safely treated with emergent angiography and embolization.
Case History
A 74-year-old man with myelofibrosis, splenomegaly, anemia, ischemic
cardiomyopathy, and a history of cholecystitis presented with jaundice and
right upper quadrant pain. Twenty months before admission he was diagnosed
with acute cholecystitis and was treated with a percutaneous cholecystostomy
tube and antibiotics. The cholecystostomy tube was removed without
complications after a cholecystogram showed a contracted gallbladder and a
patent common bile duct and no retained common bile duct stones.
Cholecystectomy was never performed because the patient was lost to
follow-up.
The patient returned to the hospital 20 months after the initial presentation with complaints of jaundice and right upper quadrant pain. On physical examination he was afebrile but tender in the right upper quadrant to palpation and jaundice. His laboratory results were remarkable for an elevated WBC of 17,100/µL (reference value, 4,800–10,800/µL), total bilirubin of 13.1 mg/dL (reference value, 0.2–1.4 mg/dL), alkaline phosphatase of 586 U/L (reference value, 30–120 U/L), aspartate aminotransferase of 198 U/L (reference value, 0–40 U/L), and alanine aminotransferase of 503 U/L (reference value, 0–50 U/L).
Right upper quadrant sonography showed a dilated common bile duct measuring 0.9 cm, but the gallbladder could not be visualized. MR cholangiopancreatography (MRCP) showed a 0.5 x 1.0 cm ovoid filling defect in a dilated distal common bile duct measuring 1.1 cm in diameter. The gallbladder was not identified on MRCP. Because of the patient's history of cholecystitis and the findings on imaging studies, the diagnosis was choledocholithiasis.
Clinical Management
The diagnosis and removal of common bile duct stones is usually performed
during endoscopic retrograde cholangiopancreatography (ERCP). Unfortunately,
ERCP was unsuccessful because a duodenal diverticulum prevented the
cannulation of the ampulla of Vater. The decision was made to perform an open
cholecystectomy and common bile duct exploration. Open cholecystectomy was
chosen over laparoscopic resection because multiple imaging studies failed to
show the gallbladder, and the general surgeon suspected that the gallbladder
was chronically scarred and contracted. This condition would make laparoscopic
cholecystectomy difficult or impossible.
The patient underwent open cholecystectomy that showed significant pericholecystic adhesions. The gallbladder was contracted with a thickened wall and adhered to the common bile duct, the second portion of the duodenum, and the gallbladder fossa by extensive adhesions. The gallbladder was eventually dissected and removed. The cystic duct and the cystic artery were ligated. A 1-cm stone was removed from the common bile duct after the exploration. Intraoperative cholangiography showed a patent common bile duct with no retained stones or abnormal filling defects. A T-tube was placed in the common bile duct.
The immediate postoperative course was complicated by multiple episodes of hypotension. The patient's hemoglobin decreased from 12.0 to 8.0 g/dL (reference value, 14–18 g/dL), requiring 5 U of transfused blood. The patient had right upper quadrant tenderness on physical examination. Bright red blood was draining through the T-tube and around the catheter tubing at the skin exit site. The patient had no complaints of melena. T-tube cholangiography was requested to confirm the positioning of the tube and to exclude a bile duct injury.
T-tube Cholangiography
T-tube cholangiography showed a nonocclusive filling defect near the hilum
that could be clots, debris, or artifacts due to incomplete distension. The
distal common bile duct was patent, and contrast material spilled into the
duodenum. The intrahepatic and extrahepatic bile ducts were not dilated. No
evidence of contrast leak was seen.
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The T-tube cholangiographic findings were normal, but this does not exclude many of the possible causes of pericatheter bleeding and hemobilia just described. Vascular injuries are commonly discovered with bile duct injuries after cholecystectomy [1, 3]. Thus, whenever a bile duct injury is suspected, an associated vascular injury also should be considered. Because this patient had signs of bleeding that were still not explained by a normal cholangiogram, CT was indicated to further evaluate potential bleeding sources.
CT
Unenhanced CT of the abdomen showed a 6-cm hyperdense fluid collection in
the gallbladder fossa (Fig.
1A). The T-tube passed adjacent to the hyperdense fluid
collection.
Expert Discussion (Dr. Regalado)
Given the clinical scenario, the hyperdense fluid collection in the
gallbladder fossa is most likely either blood, extravasated contrast material
from the T-tube cholangiography that was not detected by fluoroscopy, or a
combination of these possibilities. Unenhanced CT of the abdomen was performed
at the discretion of the primary clinical service to evaluate for an
intraabdominal hematoma. At many institutions, this scan would have been
followed by enhanced CT to assess for an area of active bleeding.
Clinical Management
Conservative management was failing in this patient, who had signs and
symptoms of active bleeding, including hypotension, a falling hemoglobin level
that was unresponsive to blood transfusions, and hemodynamic instability. On
the basis of clinical signs and the CT results, active bleeding in the
postsurgical bed was feared. The interventional radiology service was
consulted to perform emergent angiography and possible embolization rather
than repeat the CT scan with contrast material.
Catheter Angiography
Abdominal aortic angiography was performed through a right common femoral
artery puncture using a 5-French angiographic pigtail catheter. The abdominal
aortic angiogram appeared normal. A 5-French RC1 catheter (Cook, Bloomington,
IN) was used to selectively catheterize the superior mesenteric artery and
celiac artery trunk. Selective angiography of the superior mesenteric artery
showed no active bleeding or anatomic variation of the hepatic artery. Delayed
images confirmed patency of the portal vein. A selective angiogram of the
celiac artery trunk showed a normal arterial branching pattern and no obvious
bleeding. A selective angiogram of the proper hepatic artery showed a
normal-caliber and patent proper hepatic artery and right and left hepatic
arteries. The cystic artery was small in caliber and abruptly terminated in a
round focus of contrast puddling, which persisted on delayed images (Figs.
1B,
1C, and
1D). A 3-French microcatheter
was used to investigate this artery further. Catheterization was difficult
because of the small diameter and the short length of the vessel, as well as
the sharp angle of its course. The selective angiogram showed extensive
contrast extravasation into the gallbladder fossa and peritoneum, consistent
with active bleeding (Fig. 1E).
Because the distal tip of the catheter was positioned beyond the most distal
portion of the opacified cystic artery stump, the amount of contrast
extravasation was likely accentuated.
Expert Discussion (Dr. Regalado)
The true incidence of vascular injuries after cholecystectomy is uncertain
[3]. In otherwise healthy
patients, a vascular injury may be well tolerated by the patient and may be
clinically silent and undetected
[4]. However, an arterial
injury also has the potential for severe morbidity, and cases of multisystem
organ failure have been described
[1]. Arterial injuries usually
are discovered during the workup and management of associated bile duct
injuries. In patients with bile duct injuries, a risk of 12–13.8% for
arterial injury has been described
[3–5].
Some studies suggest that the risk of concomitant arterial injury is
underestimated in cases in which a bile duct injury occurs; rates of 39% after
open cholecystectomy and 47% after laparoscopic cholecystectomy have been
described [1,
3,
4]. A lower rate of arterial
injury of 7% was described in an autopsy series consisting of patients who had
undergone a prior cholecystectomy
[3,
5–7].
In terms of vascular injuries, the right hepatic artery is the most commonly
injured vessel, followed by the portal vein, which usually is injured in
combination with the proper hepatic artery
[3]. Trocar injuries also can
cause bleeding complications in the anterior abdominal wall.
This patient had adhesions from a prior episode of cholecystitis that made dissection and mobilization of the gallbladder difficult, which likely increased the risk of bleeding. Other risk factors for bleeding, such as inadequate exposure, cirrhosis, acute inflammation, portal hypertension, coagulopathy, and rough technique [8, 9], were not present.
During nonselective angiography, the source of bleeding was not identified. Instead, selective catheterization was necessary to disclose the presence and exact site of hemorrhage. When performing angiography, this sequence of observations is not uncommon. The bleeding vessel is often in vasospasm, preventing visualization of bleeding. It is possible that the amount of contrast material delivered to this vessel during nonselective angiography was insufficient to visualize the bleeding because its concentration was too low. Alternatively, during selective angiography, the rate and pressure of injection may overcome vasospasm, thus unmasking the source of bleeding.
In this patient, the bleeding artery was the cystic artery stump. Again, the most commonly injured vessel during cholecystectomy is the right hepatic artery, which was intact. Other possible sources of bleeding, such as a pseudoaneurysm, were not present. Whenever a bleeding complication occurs, the possibility of vascular injury due to variant anatomy should be considered. Many congenital variants of the cystic artery have been described, including a double cystic artery or aberrant cystic artery origins from the common hepatic artery, the left hepatic artery, or the superior mesenteric artery [10]. None of these variations was present in this patient.
Transcatheter Embolization
Two 2 x 10 mm microcoils were deployed into the bleeding cystic
artery through the microcatheter using a coil pusher. The most distal coil
lies distal to the stump of the opacified cystic artery stump. The proximal
tip of the proximal coil prolapsed slightly into the right hepatic artery. The
postembolization angiogram showed excellent hemostasis and preserved arterial
flow into the right hepatic artery (Fig.
1F).
Expert Discussion (Drs. Regalado and Funaki)
Transarterial embolization typically is used to achieve hemostasis due to
solid organ trauma, upper and lower gastrointestinal arterial hemorrhage, and
extremity and pelvic trauma. This specific case is an example of a successful
coil embolization of postoperative active bleeding from a cystic artery stump,
which is unusual and not specifically described in the medical literature.
Embolization procedures of the cystic artery are unusual, but many cases of
successful embolization of cystic artery pseudoaneurysms have been described
[11]. Embolization of hepatic
arterial branches is much more prevalent in the medical literature. Many cases
of successful embolizations of hepatic arterial pseudoaneurysms, arteriovenous
fistulas, and traumatic injuries have been published
[2,
11,
12]. Surgical interventions,
such as arterial ligation and hepatic lobectomy, can be performed if
endovascular interventions fail; however, surgical interventions are
associated with higher mortality rates
[2,
11].
A comprehensive review of embolic agents and techniques is beyond the scope of this article; however, a brief synopsis of certain embolic agents pertinent to this case follows. Many embolic agents are available, and each has certain advantages and disadvantages. In general, agents are chosen on the basis of desire to achieve temporary or permanent occlusion and the size of the vessel to be embolized. Clearly, agents also are chosen on the basis of operator experience and preference.
The target vessel in this patient had two important anatomic features that were considered before the choice of an embolic agent was made. First, the target vessel had a near-90° origin from the right hepatic artery. Second, the target vessel was short and had a narrow diameter. On the basis of these anatomic constraints, microcoils were chosen as the primary embolic agent, and two 2 x 10 mm microcoils were deployed successfully using a coil pusher. Microcoils are a permanent embolic agent that results in a proximal vessel occlusion, similar to a surgical ligation. Microcoils can be deployed accurately using fluoroscopic guidance, especially when precise placement is needed. An ideal embolization in this patient would involve this cystic artery stump only, while sparing the right hepatic artery.
Choosing the correct size coil is crucial. A coil that is too small can migrate distally, and a coil that is too large may not form properly or may extend into an arterial branch proximally, leading to nontarget embolization. In the setting of arterial injury, multiple coils are usually needed to achieve hemostasis. Because the bleeding artery was so small in this patient and already in vasospasm, hemostasis was achieved with only two microcoils.
If hemostasis was not achieved or this bleeding vessel could not be selectively catheterized, less selective embolization could have been performed, similar to the treatment protocols described for arterial bleeding in the setting of diffuse liver trauma [13, 14]. The dual blood supply of the liver limits the risk of ischemia, even with complete occlusion of the hepatic artery. Less selective embolization of the right hepatic artery could have been performed by using Gelfoam (gelatin sponge, Pharmacia & Upjohn) or coils. Gelfoam is a temporary embolic agent that is inexpensive and readily available. One of the added advantages of this temporary embolic agent is that the embolized vessel can recanalize in 2–3 weeks, allowing time for the vessel or organ to heal [13]. Gelfoam can be injected as small 1- to 2-mm torpedoes or can be mixed with contrast material to make a slurry. To make a slurry, small pieces of Gelfoam are cut up and loaded into a syringe. A small amount of contrast material is mixed with the Gelfoam; mixing is performed between two syringes using a three-way stopcock until a consistency of pudding is reached [13]. This mixture can be injected under fluoroscopic guidance until near stasis is reached, which will help prevent reflux and nontarget embolization.
Permanent embolic particles such as polyvinyl alcohol or trisacryl gelatin microspheres (Embospheres, BioSphere Medical, Rockland, MA) are not typically used in the setting of trauma because they result in a more distal and permanent occlusion that increases the risk of ischemia. As previously discussed, coils and Gelfoam have many advantages over particles in traumatic hemorrhage, making them more appropriate embolic agents for this patient.
In the future, small intravascular covered stents may play a role in controlling intraabdominal hemorrhage. Case reports and small series have described using coronary stents in the hepatic arterial circulation as a method to treat active arterial bleeding and to exclude pseudoaneurysms associated with or without bleeding. These stents have also been used to treat posttransplantation hepatic arterial anastomotic stenoses with reasonable patencies at 3, 6, and 12 months of 78%, 58%, and 45% [15–16].
Hospital Course
After the procedure, the patient became stable hemodynamically and no
postprocedural complications occurred. The patient eventually was transferred
to the inpatient rehabilitation service in good condition.
Commentary
The management of a patient with suspected postoperative intraabdominal
bleeding depends on the patient's clinical condition. If the patient is
unstable, repeated laparotomy may be the only option. If the patient has
bleeding, but is hemodynamically stable, a diagnostic study such as CT
typically is performed and is helpful in determining the presence or absence
of intraabdominal or retroperitoneal hemorrhage or solid organ injury.
Angiography and embolization commonly are performed when conservative management fails and are particularly indicated in high-risk patients who have extensive comorbidities. Regarding the emergent endovascular diagnosis and treatment, a few key clinical points should be emphasized. First, in order to identify bleeding by angiography, the patient must be actively bleeding during the examination. If the patient is not actively bleeding at the time of the examination or is bleeding intermittently, angiography will not detect the source of hemorrhage. Next, the success rate of angiographic detection is increased when angiography is directed on the basis of the clinical history or imaging. This not only saves procedure time and contrast dose to the patient, but also improves the diagnostic sensitivity when superselective microcatheter angiography can be used to detect bleeding from a vessel in vasospasm, which may be occult on less selective catheter angiography, as was shown in this patient. Finally, in the presence of coagulopathy, coil embolization may fail to achieve hemostasis because coil embolization functions to decrease perfusion pressure; an intact coagulation cascade remains necessary for prolonged hemostasis.
When embolization is undertaken emergently, the goal is to perform the procedure as quickly and safely as possible, while limiting damage to the normal parenchyma. In this case, microcoil embolization was performed and deemed the best treatment option for this patient. This form of embolization is considered more "elegant" because the technique is more time-consuming and preserves normal surrounding parenchyma. Commonly in trauma patients, the elegance of microcoil embolization must be sacrificed for the speed of achieving hemostasis and stabilizing the patient. A classic example is in the clinical setting of unstable pelvic trauma when both internal iliac arteries are embolized with Gelfoam in order to achieve rapid hemostasis [13].
In addition to the typical complications associated with angiography, such as groin hematoma, arterial dissection, and contrast nephropathy, embolization has additional complications. In published cases of embolization of pseudoaneurysms of the cystic or hepatic artery, liver infarction, bile leakage, liver abscess, nontarget embolization, and pancreatitis all have been described [2, 12]. Subselective embolization may help to avoid or minimize these complications.
References
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