A 56-year-old former intravenous drug user with chronic liver disease secondary to coexisting infection by hepatitis B and hepatitis C viruses was diagnosed with bifocal hepatocellular carcinoma in February 2018. After receiving bridging treatment using image-guided percutaneous liver microwave ablation and transarterial chemoembolization for each nodule, the patient received definitive treatment with an orthotopic liver transplant on January 1, 2019. The surgery went without complications, except for a non-significant size discrepancy between the native bile duct and the liver graft bile duct.
Nevertheless, the patient developed a stenosis of the bile duct anastomosis, which was treated 45 days later by dilating the bile duct using an expandable balloon guided by an endoscopic retrograde cholangiopancreatography (ERCP). After being discharged, the patient experienced intermittent pain in the epigastric area, which, added to a moderate amount of hematemesis and melena, led him to come to the emergency room three days later. A new ERCP was readily performed, observing significant bleeding from the duodenal papilla, unsuccessfully treated using adrenaline and argon sclerosis. Given the patient’s progressive deterioration, having to use vasoactive drugs and blood products transfusion, the attending physicians decided to refer him to our service to characterize the bleeding. A contrast-enhanced computed tomography (CT) scan was then performed, which showed a significant extravasation of contrast from the extrahepatic bile duct into the duodenum, with a smooth-walled sac adjacent and communicated to the hepatic artery in contact with the bile duct. These findings were consistent with an ABF due to a HAP (Fig. 1). Ultimately, we decided to treat the patient using endovascular therapy.
Once the patient was under general anesthesia, and after local anesthesia administration, we accessed the right femoral artery with a 6Fr introducer (Flexor Check-Flow Introducer Set®, Cook Medical). Through the introducer, we passed a 5Fr angiographic catheter (Radifocus Angiographic Catheter®, Terumo) for a selective angiography of the celiac trunk, confirming the permeability of the liver graft’s hepatic artery and the presence of a HAP with an ABF (Fig. 2a). We then placed a 5Fr introducer sheath (Radifocus Introducer II Standard Kit®, Terumo) into the common hepatic artery and a 2.7Fr microcatheter with a 0.021” hydrophilic guide to pass through the target lesion. Then we replaced the latter with a 0.014” support guide (Hi-Torque Spartacore 14®, Abbott), placing the tip in an upper segmental branch of the right hepatic artery (Fig. 2b). Finally, we decided to place a 4.5 × 15 mm balloon-expandable covered coronary stent (PK Papyrus Covered Coronary Stent System®, Biotronik, Inc.) using a rapid exchange platform (mono-rail) with a minimum guiding catheter diameter between 5-6Fr, successfully covering both the anastomosis site and the target lesion (Fig. 2c). The last angiographic series demonstrated the correct resolution of the HAP and the ABF, as well as the patency of the hepatic artery and its intrahepatic branches (Fig. 2d).
The patient presented a correct evolution during the admission, being discharged two weeks after endovascular treatment. We decided to prescribe the patient with Aspirin 100 mg/day as an antiplatelet regime during admission and indefinitely after discharge. The gastroenterology service correctly treated the biliary anastomosis stenosis by placing a biliary stent via ERCP ten weeks later, with no further complications reported. Subsequent clinical, analytical and radiological examinations demonstrated the absence of sequelae in the liver implant. Further examinations by ultrasound and CT scan up to 18 months after the procedure showed hepatic artery patency (Fig. 3).