|Year : | Volume
| Issue : | Page :
Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication
Charalampos Lampropoulos1, George Markopoulos2, Stylianos Tsochatzis3, Aggeliki Bellou4, Theofilos Amanatidis3, Dimitrios Kehagias5, George Papadopoulos6, Ioannis Kehagias5
1 Department of Surgery, General Hospital of Ilia ‘Andreas Papandreou’, Pyrgos, Greece
2 Department of Surgery, Florina General Hospital, Florina, Greece
3 Department of Surgery, General Hospital of Patras ‘St. Andrew’, Patras, Greece
4 Department of Pulmonary Medicine, General University Hospital of Patras, Patras, Greece
5 Department of Surgery, General University Hospital of Patras, Patras, Greece
6 General Surgery Clinic, IASO General Hospital, Athens, Greece
|Date of Submission||03-Aug-2020|
|Date of Decision||03-Sep-2020|
|Date of Acceptance||20-Sep-2020|
|Date of Web Publication||24-May-2021|
Naxou 4, Rio - Patras, Zip Code: 26504
Source of Support: None, Conflict of Interest: None
Background: Laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of biliary and vascular injuries. Pseudoaneurysms (PAs) following LC are rare life-threatening events with limited available experience regarding diagnosis and treatment.
Materials and Methods: An extensive review of literature during a 26-year period (1994–2020) using MEDLINE® database and Google Scholar® academic search engine revealed 134 patients with at least one symptomatic PA following LC.
Results: Nearly 81% of patients with PAs become symptomatic during the first 8 weeks following LC. The most common symptoms were gastrointestinal bleeding (74%) and abdominal pain (61%). In 28% of cases, there was a concomitant bile duct injury or leak from the cystic duct stump, whereas in about one-third of cases, PAs presented following an uneventful LC. The most common involved arteries were the right hepatic artery (70%), the cystic artery (19%) or both of them (3%). Trans-arterial embolisation was the favoured first-line treatment with a success rate of 83%. During a median follow-up of 9 months, the mortality rate was 7%.
Conclusion: Clinicians should be aware of the PA occurrence following LC. Prompt diagnosis and treatment are essential.
Keywords: Haemobilia, laparoscopic cholecystectomy, pseudoaneurysm, trans-arterial embolisation
|How to cite this URL:|
Lampropoulos C, Markopoulos G, Tsochatzis S, Bellou A, Amanatidis T, Kehagias D, Papadopoulos G, Kehagias I. Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=316868
| ¤ Introduction|| |
Prof. Dr Med Erich Mühe performed the first laparoscopic cholecystectomy (LC) in Germany in 1985. Nowadays, LC is the gold standard treatment for symptomatic cholelithiasis and one of the most commonly performed abdominal operations worldwide. However, LC is associated with higher risk of biliary and vascular injuries compared with the conventional open procedure. Vascular injuries are less common than biliary injuries, but they carry a higher mortality rate. Vascular injuries may lead to perioperative bleeding, hepatic artery infarction or pseudoaneurysm (PA) formation. Although PAs are considered a rare complication following LC, their actual incidence may be much higher. Vascular injuries that lead to PA formation are often not recognised at the time of surgery. Furthermore, PAs are characterised by an insidious and unpredictable clinical course, and they can cause severe life-threatening haemorrhage weeks to months after the LC. This article constitutes an extensive review of the literature and summarises the published experience regarding PAs following LC. Two previous reviews of the literature have been published in the past which provided valuable information on this subject.,
| ¤ Materials and Methods|| |
We conducted a literature search using the MEDLINE® database (National Library of Medicine, Bethesda, MD, USA) and Google Scholar® academic search engine (last search: 1 June, 2020) for published studies describing PA development following LC. We used the terms 'pseudoaneurysms AND laparoscopic cholecystectomy' and 'false aneurysms AND laparoscopic cholecystectomy'. Inclusion criteria were (1) original reports with at least one patient, (2) written in English language and (3) describing the occurrence of at least one symptomatic PA following LC. We included patients who underwent LC regardless of whether it was converted to open or not. In addition, (4) the formation of PAs should be attributed to the initial surgical operation and not to possible post-operative interventions (e.g., endoscopic retrograde cholangiopancreatography [ERCP], re-operation). We encompassed both case reports and case series studies. Studies in non-English language or studies with inadequate data were excluded from the analysis. Available data from eligible studies regarding patients' demographics, surgical operation, involved artery, size, clinical presentation, diagnosis and treatment of PAs as well as clinical outcome were collected and analysed.
| ¤ Results|| |
The flow diagram of the search of the literature is shown in [Figure 1]. We found 97 eligible studies and a sum of 134 patients who presented with at least one symptomatic PA following LC during a 26-year period (1994–2020).,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Patient demographics, type of surgery and pre-operative interventions
The majority of patients were women (76 of 131 patients –58%). The mean age of the patients was 50.4 (±15.0) years. Most patients (80%) were aged between 30 and 69 years. Majority of the patients (63%) underwent elective LC due to symptomatic cholelithiasis/chronic cholecystitis or gall bladder polyps, whereas the remaining patients underwent urgent or emergency LC due to acute cholecystitis [Table 1]. Ten patients had undergone pre-operative ERCP and one patient had undergone liver biopsy a few weeks before surgery.
Clinical presentation and upper gastrointestinal endoscopy findings
In 67% of the patients, PAs became symptomatic during the first 4 weeks following LC, whereas in 81% of the patients, PAs became symptomatic during the first 8 weeks following LC. However, symptomatic PAs have been mentioned up to 3 years following the initial operation. The most common symptom was gastrointestinal (GI) bleeding (74%), followed by abdominal pain, jaundice and/or elevated total/direct bilirubin, intra-abdominal bleeding and fever. GI bleeding was usually the result of haemobilia. The classic Quincke's triad of haemobilia symptoms (upper abdominal pain, upper GI haemorrhage and jaundice) was present in 32% of patients with PA. Less common symptoms included chest pain, back pain and clinical manifestations of pancreatitis [Table 2].
Patients with GI bleeding more often presented with haematemesis (59%) and less often with melaena or haematochezia. Nearly 88% of the patients with GI bleeding underwent upper GI endoscopy, whereas 10% of them had to undergo upper GI endoscopy more than once. Haemobilia was confirmed in 37% of upper GI endoscopies. However, more than half of the upper GI endoscopies did not reveal the source of bleeding. In this case, the most common findings were the presence of blood in the stomach and/or duodenum, other irrelevant findings (e.g., mycotic oesophagitis and erosive bulbitis with no active bleeding) or none. Interestingly, in four patients, upper GI endoscopy revealed extrinsic compression of the duodenum and suspected erosion from the PA [Table 3].
|Table 3: Symptoms and upper gastrointestinal endoscopy findings in patients with gastrointestinal bleeding|
Click here to view
Mechanism of injury, concomitant injuries, involved arteries and pseudoaneurysm size
The majority of cases were due to dissection or trocar injury (48 of 73 patients –66%). In 28% of cases, there was a bile duct injury or leak from the cystic duct stump. Nevertheless, in about one-third of the patients, PAs presented following an uneventful LC. The most common involved artery was the right hepatic artery (main trunk or branches –70%), followed by the remnant of cystic artery (19%), whereas in 3% of cases, PAs were located in both right hepatic artery and the remnant of cystic artery. Less commonly, the PAs were located in the abdominal aorta and proper hepatic, left hepatic, gastroduodenal and right renal arteries. The mean diameter of the PAs was 2.7 (±1.6) cm. The range of the maximum diameter was 0.4–9.1 cm [Table 4].
|Table 4: Mechanism of injury, concomitant injuries, involved arteries and pseudoaneurysm size|
Click here to view
Treatment, complications and outcome
Only 27% of the patients were treated at the institution where they underwent LC. The rest were treated in another/higher institution. Trans-arterial embolisation (TAE) was the most common first-line treatment (75%), whereas surgical repair (SR) was the second-most common first-line treatment (19%). The success rate of TAE was 83%, whereas the corresponding rate for SR was 64%. Regardless of the first-line treatment, 5% of the patients had at least one recurrence of bleeding [Table 5]. Among patients who underwent TAE, about 10% of them presented post-embolisation syndrome and/or hepatic ischaemia. A relatively rare but notable complication following TAE was the unintentional migration of coils to the adjacent anatomical structures, which caused occlusion of normal blood supply, stone formation, ascending cholangitis, acute pancreatitis, etc.. With a median follow-up of 9 months, the mortality rate was 7%. The PAs of abdominal aorta carried the highest risk of death.
| ¤ Discussion|| |
Although LC offers many well-known benefits, it is also associated with higher rates of bile duct and vascular injuries compared to that of conventional open procedure. The incidence of biliary tree injuries following LC is estimated to be up to 1%, whereas the corresponding incidence for vascular injuries is <1%.,,, Vascular injuries are more common in the presence of a bile duct injury. It is estimated that vascular injuries co-exist in approximately 25% of patients who suffer a bile duct injury. Vascular injuries during LC mainly occur either during trocar insertion or during dissection of the Calot's triangle structures. Injuries during trocar insertion are less frequent and affect the abdominal wall vessels or major intra-abdominal vessels (e.g., aorta, iliac vessels and renal vessels). These injuries are mainly caused by the placement of the optical trocar. Secondary trocars are inserted under vision and that contributes in identifying the nature of trocar injury. Injuries during dissection of the Calot's triangle structures are more common and usually affect the right hepatic artery and/or the cystic artery. Vascular injuries during LC may lead to perioperative bleeding or may present late as hepatic infarction or as PA.
PAs (also known as false aneurysms) occur when an arterial wall is injured, resulting in a rupture and formation of a sac walled by surrounding tissues and organs. Most of the PAs are iatrogenic due to surgical, endoscopic and interventional radiological procedures. Other causes include trauma and infectious and inflammatory conditions (e.g., pancreatitis and cholecystitis)., Previous studies have shown that the incidence of PAs following an LC procedure ranges between 0.06% and 0.6%,, while it is much higher (about 4.5%) in patients with a concomitant bile duct injury. However, the actual incidence of PAs following LC is underestimated. Some PAs may be too small to be identified even on imaging, whereas others may be asymptomatic, or may thrombose spontaneously.
The etiopathogenesis of PAs following LC is not clear and may be multifactorial. Injury to the arterial wall resulting in the development of a PA may be caused by the application of excessive mechanical or thermal energy, by metal clip intrusion and by the presence of bile acids or infection.,, Excessive dissection or use of electrocoagulation during the dissection of Calot's triangle may lead to laceration, transection or occlusion of an artery and a concomitant formation of a PA. Thermal energy may be transferred directly by a cautery or indirectly through a metal clip in contact with the artery. Bile acids have complex (amphipathic) solubility properties, and they are powerful solubilisers of membrane lipids. It has been shown that bile acids have fibrolytic and/or cytotoxic effects, and they delay wound healing. Other risk factors for the formation of a PA are the presence of infection, the presence of past or ongoing inflammation, the presence of anatomical variations of the bile ducts and the cystic artery and limited surgical experience.,,,
PAs following LC tend to enlarge and rupture. Rupture occurs in 21%–80% of cases, and it is associated with a mortality rate up to 43%. Aneurysms larger than 5 cm are ten times more likely to rupture. Most PAs following LC develop in the right hepatic artery or cystic artery. The time interval between LC and the onset of symptoms is variable. Most cases present during the first weeks following LC, but delayed presentation up to 5 years has been described. Unruptured PAs are usually asymptomatic or may cause abdominal discomfort and pain. Patients with ruptured PAs present with bleeding, either GI bleeding and/or intra-abdominal bleeding (haemoperitoneum). GI bleeding following PA rupture is usually the result of haemobilia. Haemobilia is defined as bleeding into the biliary tree and occurs when a fistula is formed between the splanchnic circulation and the biliary tree. Currently, about two-thirds of haemobilia cases are due to iatrogenic injuries. It is characterised by the Quincke's triad which consists of abdominal pain, jaundice and upper GI bleeding. However, the classic presentation with Quincke's triad is present in <40% of haemobilia cases. Abdominal pain is present in 70% of haemobilia cases, jaundice in 60% of cases, melaena in 90% of cases and haematemesis in 60% of cases., Rarely, haemobilia may cause acute pancreatitis.
Unruptured asymptomatic PAs may be diagnosed incidentally with conventional imaging techniques (e.g., ultrasound, computed tomography [CT] scan and magnetic resonance imaging [MRI]). The diagnosis of symptomatic or ruptured PAs requires a high index of suspicion. The presence of PA should be excluded in every patient with abdominal pain and/or symptoms and signs of bleeding during the first weeks following LC. If a patient presents without symptoms and signs of GI bleeding, an ultrasound and/or CT scan of the abdomen should be performed. Ultrasound can be utilised in the initial evaluation and has the ability to identify suspected PAs, but may not detect small PAs. Doppler ultrasound may show the 'Yin-Yang' flow within the pseudoaneurysm itself. Triple-phase contrast-enhanced CT scan or CT angiography is the most reliable non-invasive method to detect PAs. It can provide details about the location and size of the PA, it can diagnose PAs which are even thrombosed and it is also helpful in identifying abnormal vessels and anatomic variations. Ultrasound and CT scan may also reveal a fluid collection or free fluid (blood) in the peritoneal cavity.,, If a patient presents with symptoms and signs of upper GI bleeding, an upper GI endoscopy evaluation is necessary to exclude the more common causes of upper GI bleeding (e.g., peptic ulcer disease and oesophageal varices). As mentioned above, GI bleeding following PA rupture is usually the result of haemobilia. However, only 12% of cases of haemobilia are diagnosed endoscopically. In such cases, a side-view endoscopy will show a blood clot or bleeding from the ampulla of Vater. If endoscopy fails to reveal the source of bleeding, a CT scan should be the next step in evaluation. CT scan may show biliary tree dilation, GI distension or PA per se. Ultrasound may also show biliary tree dilation in 28% of cases of haemobilia. If biliary obstruction co-exists, ERCP with sphincterotomy, balloon dilatation and/or stent placement may be useful in the diagnosis of haemobilia and in the treatment of obstructive jaundice and possible bile leaks. Regardless of the presentation, conventional angiography is considered the gold standard for the diagnosis of PAs. Although conventional angiography is an invasive diagnostic method and requires a trained interventional radiologist, it remains the most accurate diagnostic method with reported sensitivity of 90%, it can determine the exact location and size of PA, it can reveal the source of bleeding and it can be quickly converted from diagnostic to therapeutic procedure.,,,,, MRI, MRI angiography and MRCP may sometimes be helpful. For instance, MRI can distinguish a blood clot from a stone in the case of obstructive jaundice.
TAE is the treatment of choice for PAs with a success rate around 75%–100%. Compared with surgery, TAE is considered a less invasive, safer and more effective option. Furthermore, TAE does not need general anaesthesia; it is a shorter procedure, it is associated with shorter length of stay and it can be repeated in the event of recurrent bleeding. Options for TAE include coils, glue, gel foam (Pfizer, MI, USA), n-butyl cyanoacrylate, polyvinyl alcohol particles and thrombin injection. Coil embolisation is the most frequently used technique. Complications of TAE include migration of coils, inadvertent occlusion of other vessels, reperfusion or rupture of PA and infection. Migration of coils in the common bile duct may lead to obstruction, stone formation, jaundice, ascending cholangitis and even pancreatitis. Inadvertent occlusion of hepatic artery may cause hepatic ischaemia and rarely liver failure. Reperfusion of PA is observed in up to 20%–25% of cases, and it may be due to a long parent artery supplying a large PA with extensive collateral circulation., Surgery is indicated when TAE fails, if it is not available or contraindicated and when there are associated injuries that require surgical treatment., Surgical options include either exclusion (ligation of feeding vessels) or excision of the PA. Percutaneous image-guided thrombin injection is another option when TAE fails. Endoscopic ultrasound-guided injection and obliteration of PAs have been used in selected cases.
The limitations of this systematic review reflect the limitations of the studies included. The majority of studies were case reports, while nine studies were small case series with 2 to 14 patients each. These studies have been published over a long period of time and originate from institutions with different levels of experience and capabilities. The main limitations were (a) the lack of a unified reporting system of the various clinical and laboratory data we examined and (b) the insufficient data in many studies, mainly regarding the type of surgery, the mechanism of injury, the size of the PAs and the follow-up. All of the above limit the validity of the conclusions.
| ¤ Conclusion|| |
PA formation following LC is a rare but potentially fatal complication. Prompt recognition and treatment are essential. Clinicians should have a high index of suspicion for every patient that present with abdominal pain or unexplained bleeding following LC. Most of the PAs are located in the right hepatic artery or in the remnant of cystic artery, and they can rupture several weeks following the initial operation. Angiography is invaluable for diagnosis in these cases. TAE is the treatment of choice for PAs following LC, while surgery should be a second-line treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS 2001;5:89-94.
Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: A national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 1993;165:9-14.
Tzovaras G, Dervenis C. Vascular injuries in laparoscopic cholecystectomy: An underestimated problem. Dig Surg 2006;23:370-4.
Halasz NA. Cholecystectomy and hepatic artery injuries. Arch Surg 1991;126:137-8.
Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2011;13:1-14.
Machado NO, Al-Zadjali A, Kakaria AK, Younus S, Rahim MA, Al-Sukaiti R. Hepatic or cystic artery pseudoaneurysms following a
Parthenis DG, Skevis K, Stathopoulos V, BellenisI, Vassilakopoulos T. Postlaparoscopic iatrogenic pseudoaneurysms of the arteries of the peritoneal and retroperitoneal space: Case report and review of the literature. Surg Laparosc Endosc Percutan Tech 2009;19:90-7.
Senthilkumar MP, Battula N, Perera M, Marudanayagam R, Isaac J, Muiesan P, et al
. Management of a pseudo-aneurysm in the hepatic artery after a laparoscopic cholecystectomy. Ann R Coll Surg Engl 2016;98:456-60.
Bulut T, Yamaner S, Bugra D, Akyuz A, Acarli K, Poyanli A. False aneurysm of the hepatic artery after laparoscopic cholecystectomy. Acta Chir Belg 2002;102:459-63.
Nicholson T, Travis S, Ettles D, Dyet J, Sedman P, Wedgewood K, et al
. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1999;22:20-4.
Madanur MA, Battula N, Sethi H, Deshpande R, Heaton N, Rela M. Pseudoaneurysm following laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2007;6:294-8.
Kumar A, Sheikh A, Partyka L, Contractor S. Cystic artery pseudoaneurysm presenting as a complication of laparoscopic cholecystectomy treated with percutaneous thrombin injection. Clin Imaging 2014;38:522-5.
Masannat YA, Al-Naser S, Al-Tal Y, Al-Koteesh J, Sharaf UI. A rare complication of a common operation: Hepatic artery pseudo aneurysm following cholecystectomy report of a case. Ir J Med Sci 2008;177:397-8.
Choudhary A, Barakat MT, Higgins LJ, Banerjee S. Choledochoscopic identification of a hepatic/cystic artery pseudoaneurysm in a patient with hematemesis after laparoscopic cholecystectomy. Dig Dis Sci 2017;62:1439-42.
Rossini M, Bonati E, Cozzani F, Marcato C, Del Rio P. Hemobilia due to cystic artery pseudoaneurysm following cholecystectomy: Diagnosis and management, a case report. Acta Biomed 2019;90:595-8.
Rencuzogullari A, Okoh AK, Akcam TA, Roach EC, Dalci K, Ulku A. Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy. Int J Surg Case Rep 2014;5:142-4.
Kumar A, Kumar D, Singh A, Jakhmola CK. Acute pancreatitis caused by hemobilia: An unusual complication of laparoscopic cholecystectomy. ACG Case Rep J 2016;3:e156.
Villa-GomezG, MahlerMA, ManazzoniD. Laparoscopic cholecystectomy complications: Anew case report of a right hepatic artery pseudoaneurysm that caused jaundice. Rev Esp Enferm Dig 2018;110:832.
Genyk YS, Keller FS, Halpern NB. Hepatic artery pseudoaneurysm and hemobilia following laser laparoscopic cholecystectomy. A case report. Surg Endosc 1994;8:201-4.
Moran J, Del Grosso E, Wills JS, Hagy JA, Baker R. Laparoscopic cholecystectomy: Imaging of complications and normal postoperative CT appearance. Abdom Imaging 1994;19:143-6.
Bergey E, Einstein DM, Herts BR. Cystic artery pseudoaneurysm as a complication of laparoscopic cholecystectomy. Abdom Imaging 1995;20:75-7.
Stewart BT, Abraham RJ, Thomson KR, Collier NA. Post-cholecystectomy haemobilia: Enjoying a renaissance in the laparoscopic era? Aust N Z J Surg 1995;65:185-8.
Yelle JD, Fairfull-Smith R, Rasuli P, Lorimer JW. Hemobilia complicating elective laparoscopic cholecystectomy: A case report. Can J Surg 1996;39:240-2.
Rivitz SM, Waltman AC, Kelsey PB. Embolization of an hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1996;19:43-6.
PorteRJ, CoerkampEG, KoumansRK. False aneurysm of a hepatic artery branch and a recurrent subphrenic abscess: Two unusual complications after laparoscopic cholecystectomy. Surg Endosc 1996;10:161-3.
Siablis D, Tepetes K, Vasiou K, Karnabatidis D, Perifanos S, Tzorakoleftherakis E. Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy: Transcatheter intraarterial embolization. Hepatogastroenterology 1996;43:1343-6.
KapoorR, AgarwalS, CaltonR, PawarG. Hepatic artery pseudoaneurysm and hemobilia following laparoscopic cholecystectomy. Indian J Gastroenterol 1997;16:32-3.
Doctor N, Dooley JS, Dick R, Watkinson A, Rolles K, Davidson BR. Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy. Br J Surg 1998;85:627-32.
Balsara KP, Dubash C, Shah CR. Pseudoaneurysm of the hepatic artery along with common bile duct injury following laparoscopic cholecystectomy. A report of two cases. Surg Endosc 1998;12:276-7.
Ribeiro A, Williams H, May G, Fulmer JT, Spivey JR. Hemobilia due to hepatic artery pseudoaneurysm thirteen months after laparoscopic cholecystectomy. J Clin Gastroenterol 1998;26:50-3.
Kwauk ST, Cameron R, Burbridge B, Keith RG. Traumatic pseudoaneurysm of the hepatic artery after percutaneous liver biopsy and laparoscopic cholecystectomy in a patient with biliary cirrhosis: A case report. Can J Surg 1998;41:316-20.
Brountzos EN, Alexopoulou E, Malagari K, Thanos L, Papaioannou G, Kelekis DA. Hepatic artery pseudoaneurysm complicating laparoscopic cholecystectomy: Management with transcatheter embolisation. Minim Invasive Ther Allied Technol 1998;7:471-473.
Halbe S, Ahmed NI, Sundar K, Sathyakumar C. Pseudoaneurysm in gall bladder fossa following laparoscopic cholecystectomy. Indian J Gastroenterol 1999;18:122.
Van Wessem KJ, Schelfhout LJ, Becking WB, de Smet AA, Lange JF. Pseudoaneurysm of the cystic artery: A rare complication of laparoscopic cholecystectomy. HPB 1999;1:231-3.
Cho NC, Kim IY, Kim DS, Kim YJ, Rhoe BS. Cystic artery pseudoaneurysm and haemobilia following laparoscopic cholecystectomy. HPB 2000;2:355-8.
Levy MM. Infected aortic pseudoaneurysm following laparoscopic cholecystectomy. Ann Vasc Surg 2001;15:477-80.
Enns R, Schmidt N, Harrison P, Chipperfield P, Skarsgaard P, Brown JA. Endoscopic diagnosis of a right hepatic artery pseudoaneurysm. Endoscopy 2002;34:337-40.
Saldinger PF, Wang JY, Boyd C, Lang E. Cystic artery stump pseudoaneurysm following laparoscopic cholecystectomy. Surgery 2002;131:585-6.
Hewes JC, Baroni ML, Krissat J, Bhattacharya S. An unusual presentation of hepatic aneurysm as a complication of laparoscopic cholecystectomy. Eur J Surg 2002;168:566-8.
Jain R, Batra Y, Acharya SK. Post cholecystectomy hemobilia: Transcatheter embolization of pseudoaneurysms with homemade steel coils. Indian J Gastroenterol 2002;21:161-2.
Lemmo G, Marrocco-Trischitta MM, Manni R, Snider F. Renal artery pseudoaneurysm and arteriovenous fistula to the inferior vena cava: A late complication following laparoscopic cholecystectomy. Am Surg 2002;68:143-5.
Yahchouchy-Chouillard E, Limot O, Ghiles E, Etienne JC, De Baer T, Picone O, et al
. Embolization for right hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. ANZ J Surg 2003;73:82-4.
ChigotV, Lallier M, Alvarez F, DuboisJ. Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Pediatr Radiol 2003;33:24-6.
Heyn J, Sommerey S, Schmid R, Hallfeldt K, Schmidbauer S. Fistula between cystic artery pseudoaneurysm and cystic bile duct cause of acute anemia one year after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2006;16:609-12.
De Molla Neto OL, Ribeiro MA, Saad WA. Pseudoaneurysm of cystic artery after laparoscopic cholecystectomy. HPB (Oxford) 2006;8:318-9.
Roche-Nagle G, Maceneaney, Harte P. Pseudo-aneurysm of the hepatic artery after laparoscopic cholecystectomy: A case report. J Minim Access Surg 2006;2:73-5.
Hasan MK, Ahmad W, Mesiya S. Hemobilia due to hepatic artery pseudoaneurysm an unusual complication after cholecystectomy and T-tube placement: 998. Am J Gastroenterol 2006;101:S394.
Majid TA, Ahmad RR, Jawad AR, Eissa AH, Mahmmod AS. Cystic artery pseudoaneurysm: A rare but serious complication after cholecystectomy report of three cases. Iraqi Acad Sci J 2007;6:164-8.
Moukaddam H, Al-Kutoubi A. Pseudoaneurysms of hepatic artery branches: Treatment with self-expanding stent-grafts in two cases. J Vasc Interv Radiol 2007;18:897-901.
Milburn JA, Hussey JK, Bachoo P, Gunn IG. Right hepatic artery pseudoaneurysm thirteen months following laparoscopic cholecystectomy. EJVES Extra 2007;13:1-3.
Sebastián JJ, Peña E, Blas JM, Ceña G. Fatal upper gastrointestinal bleeding due to hepatic artery pseudoaneurysm diagnosed by endoscopy. Dig Dis Sci 2008;53:1152-3.
Nakase Y, Takagi T, Fukumoto K, Kassai K, Yamagami T, Itani K, et al
. Hemobilia and cystic artery stump pseudoaneurysm associated with liver abscess after a laparoscopic cholecystectomy: Report of a case. Surg Today 2008;38:567-71.
Moses V, Keshava SN, Wann VC, Joseph P, Sitaram V. Cystic artery pseudoaneurysm after laparoscopic cholecystectomy presenting as haemobilia: A case report. Trop Gastroenterol 2008;29:107-9.
Srinivasaiah N, Bhojak M, Jackson R, Woodcock S. Vascular emergencies in cholelithiasis and cholecystectomy: Our experience with two cases and literature review. Hepatobiliary Pancreat Dis Int 2008;7:217-20.
Chen CC, Chen BB, Wang HP. Upper gastrointestinal bleeding owing to right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. Gastroenterology 2009;137:e5-6.
Yao CA, Arnell TD. Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Am J Surg 2010;199:e10-1.
Hylton JR, Pevec WC. Successful treatment of an iatrogenic right hepatic artery pseudoaneurysm and stenosis with a stent graft. J Vasc Surg 2010;51:1510-3.
Alis H, Bozkurt MA, Oner OZ, Dolay K, Turhan AN, Uçar A, et al
. Case report: Acute pancreatitis caused by postcholecystectomic hemobilia. BMC Gastroenterol 2010;10:75.
Giakoustidis A, McCarter D, Carter R, Imrie CW. Long-term follow-up of hepatic artery pseudoaneurysm as complication of laparoscopic cholecystectomy. Hellenic J Surg 2010;82:243-7.
Malik KA, Muneeb MD, Jawaid M, Khan ML. Post laparoscopic cholecystectomy hepatic artery pseudo-aneurysm. Pak J Surg 2010;26:89-91.
Shetty P, Selvaraju K, Singh S. A rare complication of laparoscopic cholecystectomy-hepatic artery pseudoaneurysm. Webmed Central Hepatobiliary 2010;1:WMC001304.
Ignatov V, Ivanov K, Kolev N, Tonev A. Pseudoaneurysm of the left hepatic artery-a complication following laparoscopic cholecystectomy-a case report. Script Sci Med 2010;42:95-7.
MankG, Ghosh S, ColomerA, Lukens F. Cystic artery pseudoaneurysm: A rare cause of massive GI bleed: 538. Am J Gastroenterol 2010;105:S196.
Niknam R, Afrough R, Mahmoudi L. Hemobilia due to rupture of hepatic artery pseudoaneurysm. Acta Med Iran 2011;49:633-6.
Hadj AK, Goodwin M, Schwalb H, Nikfarjam M. Pseudoaneurysm of the hepatic artery. J Gastrointest Surg 2011;15:1899-901.
Caminiti R, Rossitto M, Ciccolo A. Pseudoaneurysm of the hepatic artery and hemobilia: A rare complication of laparoscopic cholecystectomy; clinical case and literature review. Acta Chir Belg 2011;111:400-3.
Khan MR, Raza R, Salam B. Leaking pseudoaneurysm of hepatic artery: A potentially life-threatening complication of a common procedure. J Pak Med Assoc 2011;61:504-6.
Kamani L, Mosharraf SM, Tanveer-ul-Haq, ShahHA. Haemobilia: Arare cause of gastrointestinal bleeding. JColl Physicians Surg Pak 2011;21:766-8.
Sansonna F, Boati S, Sguinzi R, Migliorisi C, Pugliese F, Pugliese R. Severe hemobilia from hepatic artery pseudoaneurysm. Case Rep Gastrointest Med 2011;2011:925142.
Rajbhandari A, Bhomi KK, Pradhan GB, Shrestha S, Bhattachan CL. Post laparoscopic cholecystectomy gastro intestinal bleed. J Gen Pract Emerg Med Nepal 2011;2:60-2.
Cagli B, Tuncel SA, Sengul E, Temizoz O, Unlu E, Genchellac H, et al
. Hemobilia and occult cystic artery stump bleeding after a laparoscopic cholecystectomy: Endovascular treatment with N-butyl cyanoacrylate. Prague Med Rep 2011;112:132-6.
Petrou A, Brennan N, Soonawalla Z, Silva MA. Hemobilia due to cystic artery stump pseudoaneurysm following laparoscopic cholecystectomy: Case presentation and literature review. Int Surg 2012;97:140-4.
Butet Y, Bouras AF, Truant S, Pruvot FR. Pseudoaneurysm of the cystic artery as a complication of laparoscopic cholecystectomy. Dig Liver Dis 2012;44:449-50.
SigdelA, Morris ME, YanceyA, DwivediAJ. Endovascular management of hepatic artery pseudoaneurysm. Am Surg 2012;78:1411.
MateAD, Surnare KR, Deolekar SS, GvalaniAK. Lower gastrointestinal bleeding due to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. J Minim Access Surg 2013;9:31-3.
Panda N, Narasimhan M, Gunaraj A, Ardhanari R. Laparoscopic management of post-cholecystectomy sectoral artery pseudoaneurysm. J Minim Access Surg 2014;10:37-9.
Buyukkaya R, Aydın Ö, Erdogan C, Kaya E, Hakyemez B. Successful emergency endovascular treatment of iatrogenic giant hepatic artery pseudoaneurysm. Ann Ital Chir 2014;85:S2239253X14022087. Available from: https://pubmed.ncbi.nlm.nih.gov/25855988/
. [Last accessed on 2020 Dec 28].
El Bouhaddouti H, Mazine K, Bouassria A, Mouaqit O, Benjelloun E, Ousadden A, et al
. Hemobilia due to an iatrogenic arteriobiliary fistula complicating laparoscopic cholecystectomy: A case report. Open J Gastroenterol 2014;4:275.
Gupta S, Hariprasad S, YadavAK, Ghuman SS, GuptaA, Buxi TB. Post laparoscopic cholecystectomy cystic artery stump pseudoaneurysm: A rare complication treated with transarterial embolization. Curr Med Res Pract 2014;4:219-21.
Bin Traiki TA, Madkhali AA, Hassanain MM. Hemobilia post laparoscopic cholecystectomy. J Surg Case Rep 2015;2015:rju159.
Abdalla S, Thome A, Reslinger V, Atanasiu C, Pellerin O, Sapoval M, et al
. Compressive hematoma due to pseudoaneurysm of the right hepatic artery: A rare cause of obstructive jaundice after single-port cholecystectomy. Surg Laparosc Endosc Percutan Tech 2015;25:e42-4.
Hsiao CY, Kuo TC, Lai HS, Yang CY, Tien YW. Obstructive jaundice as a complication of a right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. J Minim Access Surg 2015;11:163-4.
Raashed S, Chandrasegaram MD, Alsaleh K, Schlaphoff G, Merrett ND. Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation. BMC Surg 2015;15:51.
Feng W, Yue D, ZaiMing L, ZhaoYu L, Wei L, Qiyong G. Hemobilia following laparoscopic cholecystectomy: Computed tomography findings and clinical outcome of transcatheter arterial embolization. Acta Radiol 2017;58:46-52.
Alrajraji M, Nawawi A, Jamjoom R, Qari Y, Aljiffry M. Delayed hemobilia due to hepatic artery pseudo-aneurysm: A pitfall of laparoscopic cholecystectomy. BMC Surg 2016;16:59.
Arteaga, AS, Orue-Echebarria MI, Zarain L, Lusilla A, Martinez CM, Moreno A, et al
. Acute bleeding from pseudoaneurysms following liver and pancreatobiliary surgery. Eur J Trauma Emerg Surg 2017;43:307-11.
Badillo R, Darcy MD, Kushnir VM. Hemobilia due to cystic artery pseudoaneurysm: A rare late complication of laparoscopic cholecystectomy. ACG Case Rep J 2017;4:e38.
Zaafouri H, HasnaouiA, Essghaeir S, Haddad D, Sabbah M, Bouhafa A, et al
. Ascending cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report. BMC Surg 2017;17:30.
Gachabayov M, Kubachev K, Mityushin S, Zarkua N. Recurrent hemobilia due to right hepatic artery pseudoaneurysm. Clin Med Res 2017;15:96-9.
Kassem TW. Right hepatic artery pseudoaneurysm as complication of laparoscopic cholecystectomy. Egypt J Radiol Nucl Med 2017;48:931-3.
Yagihashi K, Kamo M, Nishiyama T, Kurihara Y. Percutaneous direct embolization for pseudoaneurysm at the gallbladder fossa after cholecystectomy. Ann Vasc Dis 2017;10:234-7.
CreŢu OM, Dan RG, Blidişel IA, Sima LV, Munteanu M, Păun I. Hemobilia through aneurysm of the right hepatic artery, 22 months after laparoscopic cholecystectomy: Case presentation. Rom J Morphol Embryol 2017;58:197-9.
To K, LaiE, Chung D, ChanO, TangCN. Cystic artery pseudoaneurysm with haemobilia after laparoscopic cholecystectomy. Hong Kong Med J 2018;24:203-5.
Schreuder AM, van Gulik TM, Rauws EA. Intrabiliary migrated clips and coils as a nidus for biliary stone formation: Arare complication following laparoscopic cholecystectomy. Case Rep Gastroenterol 2018;12:686-91.
Canales R, del Castillo M, García-Encinas C, Plasencia A, Sierralta D. Transarterial embolization of a hepatic pseudoaneurysm with hemobilia. J Angiol Vasc Surg 2018;3:12.
Nasa M, Sharma ZD, Patil G, Puri R. Coil migration into common bile duct after postcholecystectomy hepatic artery pseudo-aneurysm coiling. J Dig Endosc 2018;9:205-7. [Full text]
Desai GS, Pande P, Narkhede R, Kulkarni DR. Revision Roux-en-y hepaticojejunostomy for a post-cholecystectomy complex vasculobiliary injury with complete proper hepatic artery occlusion: A case report and literature review. Int J Surg Case Rep 2019;58:6-10.
Luthra A, Das D, Mohapatra M, Panigrahi SK, Pujari PS. Hemobilia: An unusual and life threatening complication of laparoscopic cholecystectomy. Int Surg J 2019;6:3406-8.
Al-ZayerFA, AlzahirMA, AbualsaudBA, Al-Jaroof AH, MeshikhesAN. Giant hepatic artery aneurysm post laparoscopic cholecystectomy. Radiol Diagn 2019;3:1-2.
Abiko T, Ebihara Y, Takeuchi M, Sakamoto H, Homma H, Hirano S. Hemobilia-a rare complication after laparoscopic cholecystectomy. Surg Case Rep 2020;6:91.
Sidhu A, Shaik NB, Sharma M. Endoscopic and percutaneous ultrasound-guided thrombin and glue injection in a pseudoaneurysm of the right hepatic artery. Endoscopy 2020;52:E245-6.
A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991;324:1073-8.
Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93:158-68.
Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005;25 Suppl 1:S173-89.
Cordova AC, Sumpio BE. Visceral artery aneurysms and pseudoaneurysms should they all be managed by endovascular techniques? Ann Vasc Dis 2013;6:687-93.
Hofmann AF. Bile acids: The good, the bad, and the ugly. News Physiol Sci 1999;14:24-9.
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
Christensen T, Matsuoka L, Heestand G, Palmer S, Mateo R, Genyk Y, et al
. Iatrogenic pseudoaneurysms of the extrahepatic arterial vasculature: Management and outcome. HPB (Oxford) 2006;8:458-64.
Green MH, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg 2001;88:773-86.
Horton KM, Smith C, Fishman EK. MDCT and 3D CT angiography of splanchnic artery aneurysms. AJR Am J Roentgenol 2007;189:641-7.
Machida H, Ueno E, Shiozawa S, Fujimura M, Tsuchiya A, Kim DH, et al
. Unruptured pseudoaneurysm of the cystic artery with acute calculous cholecystitis incidentally detected by computed tomography. Radiat Med 2008;26:384-7.
Carey F, Rault M, Crawford M, Lewis M, Tan K. Case report: Cystic artery pseudoaneurysm presenting as a massive per rectum bleed treated with percutaneous coil embolization. CVIR Endovasc 2020;3:8.
Laing FC, Frates MC, FeldsteinVA, GoldsteinRB, Mondro S. Hemobilia: Sonographic appearances in the gallbladder and biliary tree with emphasis on intracholecystic blood. J Ultrasound Med 1997;16:537-43.
Napolitano V, Cirocchi R, Spizzirri A, Cattorini L, La Mura F, Farinella E, et al
. A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy. World J Emerg Surg 2009;4:37.
Senadhi V, Arora D, Arora M, Dutta S. Hemobilia caused by a ruptured hepatic cyst: A case report. J Med Case Rep 2011;5:26.
Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al
. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276-83; discussion 283.
Vaidya S, Tozer KR, Chen J. An overview of embolic agents. Semin Intervent Radiol 2008;25:204-15.
LiuTT, Hou MC, LinHC, ChangFY, Lee SD. Life-threatening hemobilia caused by hepatic artery pseudoaneurysm: A rare complication of chronic cholangitis. World J Gastroenterol 2003;9:2883-4.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]