Biliovenous fistula represents the most common source of bleeding after percutaneous
transhepatic biliary drainage (PTBD), and the course is usually self-limiting [1]. Severe hemobilia from arteriobiliary fistula must be expected in 0.4 % [2] to 2 % [3] of all procedures performed and often necessitates immediate treatment by selective
arterial embolization [2] or transbiliary embolization [4]. We report here the simultaneous perforation of a lobar hepatic artery, a lobar
portal vein, and the central right portal vein during PTBD for choledocholithiasis.
A 76-year-old woman with a history of cholecystectomy and Billroth II gastrectomy
was admitted to our institution because of multiple bile duct stones and a common
bile duct stricture, diagnosed by computed tomography (CT) scan and endoscopic retrograde
cholangiography. PTBD was done using a right intercostal approach, revealing massive
dilatation of intrahepatic bile ducts and several large calculi on top of a high-grade
common bile duct stenosis. After a Terumo wire had been passed through the stricture,
a 10-Fr pigtail drainage catheter was successfully placed in the duodenum. When the
pigtail catheter was removed for further tract dilation, 7 days later, massive bleeding
occurred from the percutaneous tract, which was controlled by deep placement of a
12-Fr Nimura catheter without sideholes. Selective hepatic arteriography was immediately
performed, and showed normal hepatic artery branches without arteriobiliary fistula.
However, a portobiliary fistula within S8 and a centrally located lesion of the right
portal vein were suspected. The portobiliary fistula was verified by retraction of
the PTBD device (Figure [1 a]) and the perforated vessel was embolized using a direct transhepatic approach (Figure
[1 b]). Since the right portal vein lesion could not be reached via this approach, direct
portography was performed, confirming circumferential extravasation of contrast medium
from the right portal vein close to the bifurcation (Figure [2]), and a Yomed Covered Stent (18 mm length, 10 mm central and 8 mm peripheral diameter)
was placed to cover the lesion. After a second PTBD device had successfully been placed,
via S6, 4 days later, an attempt was being made to remove the Nimura drainage catheter
within the first tract, when once again, there was massive bleeding of sudden onset
from the percutaneous tract. Retrograde tracing now revealed an arteriobiliary fistula
within S8 (Figure [3 a]). Selective arteriography was performed and the perforated hepatic artery branch
was embolized by the application of endocoils (Figure [3 b]). No more bleeding was observed, the Nimura catheter was removed, and further therapy
was successfully performed by percutaneous cholangioscopy and laser lithotripsy, after
dilation of the second tract. This report describes, for the first time to our knowledge,
recurrent serious bleeding episodes after PTBD, from three different lesions of major
hepatic blood vessels including the hepatic artery and portal vein. We conclude that
severe bleeding complications, with delayed onset and from multiple locations, may
occur with PTBD, and that adequate interventional angiography facilities should be
available when PTBD is carried out.
Figure 1
a PTCB revealing massively dilated bile ducts with intraluminal blood coagula. Retrograde
tracing of the S8 lobar portal vein (arrow) on retraction of the pigtail catheter
is shown. b Percutaneous transhepatic embolization of the perforated lobar portal vein.
Figure 2 Direct portography shows circumferential extravasation of contrast medium from the
right portal vein (arrow). Note the percutaneous transhepatic biliary drainage (PTBD)
tract (arrowheads) in the immediate vicinity.
Figure 3
a Retrograde tracing via PTBD revealing arteriobiliary fistula within S8 (arrow).
The covered stent (arrowhead) which had been placed in the right portal vein is in
situ. b Selective angiography image of S8 hepatic artery branch before successful application
of endocoils (not shown).
