Right hepatic arterial injury is a common vascular injury during laparoscopic cholecystectomy, occurring in approximately 25 % of patients with biliary injuries [1]. We report the case of a 78-year-old man who, 1 month after undergoing a laparoscopic cholecystectomy, was referred for hemobilia and collapse caused by the rupture of a cystic artery pseudoaneurysm into the common bile duct (CBD). Angiography showed active bleeding that was treated by conventional coil embolization [2] ([Fig. 1]).
Fig. 1 Angiographic image in a 78-year-old man with rupture of a cystic artery pseudoaneurysm into the common bile duct, 1 month after undergoing a laparoscopic cholecystectomy, that was treated with coil embolization.
The patient was re-referred with obstructive cholangitis 1 month later ([Fig. 2]), but endoscopic retrograde cholangiopancreatography (ERCP) failed owing to a bile duct stricture that could not be passed. We then performed percutaneous transhepatic biliary drainage to gauge the stricture over the course of a year ([Fig. 3 a]). We removed the drain after 1 year with correct sizing of the stricture, but cholangitis subsequently recurred, requiring further percutaneous drainage prior to performing percutaneous cholangioscopy (CHF type V choledochoscope; Olympus, Tokyo, Japan). During cholangioscopy, we identified coils that had migrated into the CBD and easily removed these by pushing them with a biopsy forceps into the duodenum ([Fig. 3 b]; [Video 1]). The patient was discharged with transhepatic drainage for an additional 3 months ([Fig. 3 c]). We hope that the removal of the coils will improve CBD healing, although we fear the development of an ischemic biliary stenosis.
Fig. 2 Biliary magnetic resonance imaging performed after the patient developed obstructive cholangitis.
Fig. 3 Fluoroscopic images showing: a the initial cholangiographic appearance after percutaneous transhepatic biliary drainage; b coil removal during percutaneous cholangioscopy; c follow-up cholangiographic image.
Video 1 Percutaneous cholangioscopy to remove endovascular coils that had migrated into the bile duct after right hepatic artery pseudoaneurysm embolization.
Few cases of coil migration into the CBD have been reported [3] and ERCP treatment has been suggested [4], but the percutaneous approach is another option. In this video, we demonstrate the removal of migrated coils with a percutaneous endoscopic approach, thereby avoiding complex surgery.
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