Pseudoaneurysm of the cystic artery

Clinical History

74-years-old men had upper abdominal pain with nausea, alimentary vomiting and jaundice. On examination, he had a low-grade fever (37.2ºC) and epigastric tenderness without guarding. He was slightly icteric.

Imaging Findings

74-years-old men had upper abdominal pain with nausea, alimentary vomiting and jaundice. He had a prior history suggestive of cholecystitis gallstone disease. On examination, he had a low-grade fever (37,2ºC) and epigastric tenderness without guarding. He was slightly icteric. Laboratory findings showed a disturbance of the liver blood test (); haemoglobin was 11,3 g/dl and white blood cell count was /mm, with left shift. Initial abdominal ultrasonography revealed a distended gallbladder with thickening of the wall and a 3 cm hyperechogenic mass inside its lumen and a normal biliary ductal system. Initially he was treated conservatively. Some days later he had a massive episode of melaena. Upper gastrointestinal tract endoscopy was performed immediately, and blood was seen coming out the papilla. A computed tomography evaluation of the abdomen demonstrated a distended gallbladder with a thick walled and revealed a haematoma within the gallbladder, surrounding a nodular image enhanced by contrast material injection. A diagnose of arterial pseudoaneurysm was made. Selective arteriography of the hepatic artery was immediately performed and revealed a pseudoaneurysm of the cystic artery with extravasation of contrast material. Hiperselective catheterization of this branch allowed embolization using 2 coils (6-6mm). Subsequent injection of the cystic artery showed absence of opacification of the aneurismal arterial branch. Immediate follow-up was marked by a rapid disappearance of symptoms and a return of the liver tests to normal levels.

Discussion

Pseudoaneurysm of the cystic artery is rare. Most commonly involved artery is branches of right hepatic and gastroduodenal artery. The aetiology of pseudoaneurysm of the hepatic artery and its branches is manifold, and includes blunt abdominal trauma, previous surgery of the biliary tract, cholecystitis, pancreatitis and has also recently been reported as a complication of laparoscopic cholecystectomy. All of the stimuli act to partial erosion of the components of the arterial wall to give rise to the pseudoaneurysm. The aetiology of the pseudoaneurysm in this patient was probably the acute cholecystitis previous. Eighty percent of the patients with pseudoaneurysm of the hepatic artery or its branches present with bleeding. Hemobilia appear in 45%. Epigastric pain and Quincke triad (biliary colic, jaundice and gastrointestinal bleeding) are the commonest symptoms. Standard ultrasonography and contrast enhanced Computed Tomography may show findings similar to those of pseudoaneurysms elsewhere but is no invariable, particularly when the aneurysms are small and contain thrombus. Pulsed Doppler ultrasound scanning may show characteristic pulsatile blood flow within the aneurysm. The most useful investigation is selective mesenteric angiography as both the diagnosis and the accurate delineation of vascular relationships can be made before treatment by radiological embolization or surgical repair. In case of cholecystitis-related pseudoaneurysm, urgent cholecystectomy is obviously the treatment of choice. Nevertheless, if the diagnosis is revealed by arteriography, transcatheter embolization should be attempted because it only slightly prolongs the duration of the procedure, permits the delay of intervention in unstable patients, allows bleeding control during operation, and does not impede surgical procedures.

Differential Diagnosis List

Final Diagnosis

Pseudoaneurysm of the cystic artery

URL:	https://eurorad.org/case/3870
DOI:	10.1594/EURORAD/CASE.3870
ISSN:	1563-4086