Dear Editor,

A 39-year-old male patient presented to our institution with acute cholangitis. Four weeks prior to this event, he had undergone a laparoscopic cholecystectomy (LC) at another institution. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with plastic stent placement due to a hepatic common bile duct stenosis. A metallic clip was visualized around the stenosis, although it did not seem to be the cause (Fig. 1A). In addition, an extrinsic compression was observed at the level of the duodenal bulb, which also had congestive mucosa (Fig. 1B). An angiotomography identified a pseudoaneurysm of the right hepatic artery (Fig. 1C).

Fig. 1 A. Cholangiography shows a common hepatic duct stenosis. Adjacent to the stenosis, a metallic clip is observed. B. At the duodenal bulb, an extrinsic compression area with congestive and friable mucosa is observed. C. Angiotomography shows a lobed isodense lesion with fast filling at the arterial phase, compatible with a pseudoaneurysm of the right hepatic artery. 

The patient improved clinically and unfortunately had an episode of massive hematemesis seven days after the biliary drainage. Arteriography with embolization of the pseudoaneurysm was performed without any further complications. Four weeks later, another ERCP was performed and the plastic stent was removed and the cholangiogram showed a complete resolution of the stenosis.

Discussion

We present a new case of a right hepatic artery pseudoaneurysm (HAP). Our case is unlike those previously reported in this journal 1. The patient presented with obstructive jaundice as an initial clinical manifestation, which is infrequent within an infrequent pathology.

Iatrogenic vascular lesions such as the HAP are uncommon and serious complications of LC 1. The mortality rate associated with rupture of a hepatic artery pseudoaneurysm has been reported to be as high as 40% 3. The clinical manifestations are variable but gastrointestinal bleeding secondary to hemobilia is the most frequent presentation. Obstructive jaundice due to compression of the bile duct by the right HAP is very infrequent 4.

The first line of treatment for HAP is the embolization of the affected artery 5. Surgery is reserved for patients in whom the angiographic treatment has failed and those who have other associated injuries, such as bile duct leaks, stenosis, infected biolomas, etc., which require concomitant surgical treatment.

Bibliografía

1. García-Moreno JL, Ocete Pérez RF, Suárez Artacho G, et al. Pseudoaneurisma de arteria hepática derecha postcolecistectomía. Rev Esp Enf Dig 2011;103(2):99-100. [ Links ]

2. Tessier DJ, Fowl RJ, Stone WM, et al. Iatrogenic hepatic artery pseudoaneurysms: an uncommon complication after hepatic, biliary, and pancreatic procedures. Ann Vasc Surg 2003;17(6):663-9. DOI: 10.1007/s10016-003-0075-1 [ Links ]

3. Abbas MA, Fowl RJ, Stone WM, et al. Hepatic artery aneurysm: factors that predict complications. J Vasc Surg 2003;38(1):41-5. DOI: 10.1016/S0741-5214(03)00090-9 [ Links ]

4. Hsiao CY1, Kuo TC, Lai HS, et al. Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. J Minim Access Surg 2015;11(2):163-4. [ Links ]

5. Nicholson T, Travis S, Ettles D, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1999;22(1):20-4. DOI: 10.1007/s002709900323 [ Links ]