Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction

Objectives: To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO). Methods: From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52–82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE. Results: The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22–2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein. Conclusion: TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO. Advances in knowledge: This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.

Hemobilia in percutaneous transhepatic cholangiostomy

Aim. To determine the dependence of the formation of vascular-biliary fistula with the bile ducts bleeding and along the drainage channel on the diameter of the puncture needle and access to the biliary tract.Materials and methods. A retrospective analysis of the results of treatment of 3786 cases of percutaneous transhepatic cholangiostomy using needles 17.5-18 G under Amplatz 0.035’ conductor with a safe J-tip was carried out. In the cholangiostomy in the bile ducts was installed biliary tree drainage shape memory No 8 Fr. In benign lesions of the bile ducts 2066 (54.6%) interventions were performed, 1720 (45.4%) for malignant ones. Central access to the bile ducts was performed in 2442 cases (64.5%), peripheral – in 1344 cases (35.5%).Results. Significant hemobilia was observed in 21 (0.55%) cases: in 8 (0.47%) with a obstructive jaundice of malignant etiology, in 13 (0.63%) – benign etiology. In 3 cases, the cause of hemobilia was arteriobiliary fistula, in 16 – portobiliary, in 2 – biliovenous fistula. Central access was complicated by significant hemobilia in 10 patients, peripheral – in 11.Conclusion. The low frequency of significant hemobilia – 0.55% – when using puncture needles 17.5–18 G for primary access to the bile ducts proves the validity of their use in radiological practice, and also does not allow to consider central access critical for the development of hemorrhagic complications in percutaneous transhepatic biliary drainage.

Fístula portobiliar como complicación mayor de biopsia hepática transpercutánea bajo marcación ecográfica

Woman of 71 years, in study of chronic liver disease, Child-Pugh A, computed tomography (CT) suggestive of cirrhosis, autoimmune hepatitis score probable. It was decided to perform a liver percutaneous biopsy for diagnosis and treatment. After the procedure, the patient presented a self-limited episode of hematemesis. Upper digestive endoscopy without blood or other injury, abdominal ultrasound without free liquid. The patient was hospitalized, evolving hemodynamically stable without new bleeding episodes. Medical discharge was decided after 24 hours of observation. The patient consults the next day at emergency room because of intense abdominal pain and anemia. CT Impressed a dilated bile duct with hyperdense content inside, so she was rehospitalized. The patient evolved with melaena and hypotension. Biliary hematoma due to arteriobiliary fistula was suspected. CT angiogram evidenced portobiliary fistula. It was managed with endovascular therapy but the patient remained hypotense with a requirement for vasoactive drugs and multi-organ dysfunction, and she finally died.