Management of Bleeding

after Percutaneous Transhepatic

Cholangiography or Transhepatic Biliary Drain Placement
Wael E.A. Saad, MBBCh,a Mark G. Davies, MD, PhD,a and Michael D. Darcy, MDb

Bleeding complications occur in 2 to 3% of percutaneous transhepatic biliary drains. These

complications include: hemothorax, hemoperitoneum, subcapsular hepatic bleeding, he-
mobilia, melena, and bleeding from the percutaneous biliary drain. The bleeding sites can
be classified into (1) perihepatic bleed sites (hemothorax, hemoperitoneum, subcapsular
hepatic hematoma), (2) gastrointestinal bleeding (hemobilia and/or melena), and (3) bleed-
ing from the percutaenous biliary drain itself, which is the most common clinical presen-
tation. There are several bleeding sources. These include skin-bleeds, intercostal artery,
portal vein, hepatic vein, and the hepatic artery. There are a variety of maneuvers that can
be utilized in the management of bleeding percutaneous biliary drains. These include
tractography, angiography, tract embolization, arterial embolization, and tract site changes.
This article proposes a protocol for approaching bleeding complications after percutaneous
biliary drain placement and details the diagnostic and therapeutic procedures in the
management of these bleeding complications.
Tech Vasc Interventional Rad 11:60-71 © 2008 Elsevier Inc. All rights reserved.

KEYWORDS percutaneous biliary drain, hemorrhage, angiography, embolization, arterial injury

B leeding complications occur in 2 to 3% of percutaneous

transhepatic biliary drains.1-3 These complications in-
clude hemothorax, hemoperitoneum, subcapsular hepatic
vital signs (up to patient instability) without bleeding into or
around the PBD should prompt the interventionalist to perform
an imaging examination, such as a chest radiograph, to rule out
bleeding, hemobilia, melena, and bleeding from the percuta- hemothorax or a noncontrast lower thoracic and upper abdom-
neous biliary drain (PBD).2,3 The bleeding sites can be classi- inal CT to rule out intrathoracic and/or intraabdominal bleeding
fied into (1) perihepatic bleed sites (hemothorax, hemoperito- (hemothorax, hemoperitoneum, or subcapsular hematoma)
neum, subcapsular hepatic hematoma), (2) gastrointestinal (Fig. 1).
bleeding (hemobilia and/or melena), and (3) bleeding from To reduce confusion, the remainder of this article focuses on
the percutaenous biliary drain itself, which is the most com- the management of bleeding from and around the biliary drain
mon clinical presentation. There are several sources for these (Fig. 2). However, extrapolating the thought process for other
kinds of bleeding presentations. Table 1 lists the source ves- types of bleeding complications from PBD placement can be
sels and their most likely presentations. made throughout the article.
Because of the variety of bleeding sources and types of injury
and their sites, there are a variety of maneuvers that are plausible
in the management of bleeding PBD. The authors of this article Reducing the Risk of
offer a thought process for approaching this set of bleeding com-
plications. Hemorrhagic Complications
The subject can be broadly divided into perihepatic bleeding When planning transhepatic needle access in the biliary tract,
and bleeding from the PBD itself. First, proof of ongoing bleed- particularly with the intention of placing a biliary drain, the
ing has to be made. This obviously is not a problem in cases of operator should attempt to avoid the central bile ducts as much
continued bleeding from the PBD. However, deterioration of as possible (Fig. 3). Central bile ducts are accompanied by larger
and more crowded blood vessels and the likelihood of trans-
gressing an artery or large vein is higher.2 In addition, the oper-
aUniversityof Rochester, Rochester, NY.
bMallinckrodt
ator should pass the definitive access needle and subsequently
Institute of Radiology, Washington University, St Louis, MO.
Address reprint requests to: Wael E.A. Saad, MBBCh, University of Roches-
the PBD above the ribs to avoid the intercostal neurovascular
ter Medical Center, Department of Imaging Sciences, 601 Elmwood Ave, bundle (intercostal vessels and nerves), which usually run infe-
Box 648, Rochester, NY 14642. E-mail: [email protected] rior to the ribs (Fig. 3, also see Figs. 1 and 2 in Transhepatic

60 1089-2516/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.

doi:10.1053/j.tvir.2008.05.007
Bleeding complications 61

Table 1 Source Vessels for Bleeding, Possible Presentations and Management

Source Type of injury Presentation Management
Skin Bleeding around drain Self limiting, purse string suture,
correct coagulopathy
Intercostal artery X Extravasation X Hemothorax X Usually self limiting
X Pseudoaneurysm (not X Chest wall hematoma X Embolization, chest tube
common) X >200 mLh from chest tube
may need surgery
Hepatic artery X Transection/extravasation X Bleeding in drainage bag X Angiography and embolization
X Pseudoaneurysm X Bleeding around drain (see Fig 2)
X Arterioportal fistulae X Hemobilia/melena X Surgery (difficult and rarely
X Arteriohepatic vein fistulae X Patient instability resorted to nowadays)
(rare) X Chronic intermittent bleeding
X Subcapsular hematoma or
intraperitoneal hemorrhage
Portal vein X Transection X Bleeding in drainage bag X Drain upsizing (see Fig 2)
X Arterioportal fistulae X Hemobilia/melena X Correct coagulopathy
X Patient instability (not X Tract changing and
common) embolization (see Fig 2)
Hepatic vein (rare) X Usually part of a complex X Bleeding in drainage bag X Drain upsizing (see Fig 2)
injury/complex filstulae X Hemobilia/melena X Correct coagulopathy
X Tract changing and
Patient instability (not common)
embolization (see Fig 2)

Techniques for Accessing the Biliary Tract, this issue). Choosing a drain is patent (flushed easily without resistance), a purse string
skin entry site above a rib is performed by palpation Further- suture may be applied to try to compress/ligate a possible skin-
more, the operator should examine the skin of the planned entry bleed. In addition, a chest radiograph can be performed to rule
site, looking for dilated veins that should be avoided. out pleural effusion (possible hemothorax).
In addition, coagulopathy levels should be screened. There If the bleeding is in the biliary drainage bag, the bleeding
is no set minimal value for the international normalized ratio should be assessed for quantity and character. Character refers
(INR) nor for the platelet count required before commencing to whether the fluid in the bag is sanguineous bile or frank
a percutaneous transhepatic cholangiography and PBD blood. Bile with a sanguineous tinge can be expected and, if the
placement. It is left to the individual operator’s “comfort patient is stable, serial hematocrits and observation of drain out-
level.” The present authors suggest a maximum INR of 1.4 put (quantity and character) are not unreasonable (Fig. 2).
and 1.6 in elective cases and emergent cases, respectively, as Frank bleeding in the bag requires the tube to be capped in an
well as a minimum platelet count of 70,000 and 50,000/mm3 attempt to tamponade the bleeding. Serial hematocrits and vital
in elective cases and emergent cases, respectively. However, sign assessment should be performed. If frank bleeding exceeds
appropriate parameters should be placed by institutions 200 to 250 mL/h in the bag (anecdotal, extrapolated from the
and/or be left to the individual operator’s “comfort level,” cardiothoracic surgery literature for thoracotomy and surgical
which may be tailored to individual clinical situations. exploration based on bleeding chest tube output) and/or the
patient is unstable, the patient should be moved to the angiog-
raphy suite with the tube capped.
Bedside Measures of
Bleeding PBDs Including
Local Control of Bleeding Transhepatic Tractography
At bedside the first thing that should be assessed is the patient’s
and Transhepatic Procedures
stability. The patients’ vital signs should be compared with their Some operators consider a transhepatic tractogram as the first
baseline. Some relative hypotension can be expected after mod- imaging investigation based on that the likelihood that a venous
erate sedation. In addition, the patients’ blood should be typed injury is higher than the likelihood of an arterial injury particu-
and crossed ready for blood transfusion should the hematocrit larly in a stable patient. Other operators would go directly to an
be low. The target should be a hematocrit above 30%. Second, arteriogram (see below) to rule out a significant injury that can
the actual site of the bleeding, if apparent, should be assessed. potentially be dealt with decisively by endoluminal means.2 Fur-
The bleeding could be through the PBD and into the collecting thermore, having contrast in the biliary tract may obscure the
bag and/or it could be from around the drain, soiling the dress- arterial injury if a subsequent arteriogram is performed.2 The
ing. Soiled dressing should be taken down and removed by a current authors make that decision (tractogram versus arterio-
physician to assess the extent of bleeding. Oozing around the gram) based on patient stability (Fig. 2).
drain could be a skin-bleed, an intercostal vessel injury, or a Technically, a tractogram is performed by removing the
partly tamponaded arterial bleed. Squirting blood is an ominous transhepatic biliary drain over a wire and replacing it with a
indication of an arterial injury (intercostal versus hepatic artery). vascular sheath on French smaller than the size of the PBD. That
If there is slow oozing bleeding around the drain only and the is to say, replace an 8-French PBD with a 7-French vascular
62 W.E.A. Saad, M.G. Davies, and M.D. Darcy

Figure 1 Post difficult percutaneous transhepatic cholangiogram (PTC) in a liver transplant recipient. The patient is
stable but his heart rate has risen and his blood pressure has dropped, which is concerning for internal bleeding.
(A) Non-IV contrast axial CT image at the level of the aortic hiatus showing contrast in the biliary ducts from the PTC.
There is a subcapsular hematoma, B. (B) Non-IV contrast axial CT image at the level of the kidneys showing the extent
of the subcapsular hematoma, B. (C) Digital subtraction angiogram (DSA) of a selective intrahepatic right hepatic artery
arteriogram. The DSA demonstrates active extravasation of contrast (active bleeding) (arrow). (D) Magnified DSA of a
selective intrahepatic right hepatic artery arteriogram. The DSA demonstrates active extravasation of contrast (active
bleeding) (arrow) and a small arterioportal fistula (APF) (arrowheads).
Bleeding complications 63

Figure 2 Flowchart describing the approach to bleeding from or around a percutaneous biliary drain. First line bedside
measures include the following: assess consciousness and stability by checking vital signs (compare with base line);
type and cross at least 2 units of pRBC; cap percutaneous biliary drain (PBD); take down soiled dressing and examine
site of bleeding. **Global/segmental gelfoam embolization (not with liver transplants or advanced cirrhotics): Global
or segmental embolization of the hepatic artery using gelfoam is an attempt to reduce the perfusion of the liver or the
segment of the liver where the PBD passes through. This is a rare scenario and should be considered as a last line
procedure. It is rare because it is very difficult to have a hemorrhagic PBD complication that forces an operator’s hand
to perform a therapeutic procedure without being able to identify a vascular injury. Nevertheless, the option can be
entertained in this rare situation.*** Urgent surgery: Urgent surgery is rarely resorted to nowadays. This is because
most PBD bleeding does not warrant this difficult surgery or, if significant, the bleeding can be dealt with decisively via
transhepatic and/or endoluminal means. Nevertheless, these surgical procedures have been described (particularly for
APF) historically. They are difficult and often bloody surgeries because the injury is often deep and with few vicinity
land marks. These surgeries include hepatic segmentectomies and arterial ligations. HCT%, hematocrit (RBC concen-
tration in blood); THT, transhepatic tract; PsA, pseudoaneurysm; APF, arterioportal fistula; LFTs, liver function tests.
64 W.E.A. Saad, M.G. Davies, and M.D. Darcy

patic injection can cause pain and may increase the risk of
cholangitis and even sepsis. Once a hepatic artery injury is iden-
tified or suspected, the vascular sheath is replaced by an upsized
drain to tamponade the injury and temporize the situation. At-
tention is then drawn to a formal percutaneous transcatheter
hepatic arteriogram (see below).
Changing the transhepatic tract site and embolizing the old
transhepatic tract can be contemplated in two uncommon sce-
narios.2,4 The first scenario is chronic insidious bleeding with no
vessel identified by tractography or arteriography. In this case
changing the transhepatic tract site and embolizing the old tract
(Fig. 8) may clear up the bleeding. The second scenario that
requires a tract change and transhepatic embolization is an iden-
tified transgressed vein that does not heal. Tract site change may
also be more encouraging if the above two scenarios are com-
pounded by another tract site complication such as morbid site
pain and respiratory splinting due to irritation of intercostal
nerves by the PBD or the tract has transgressed the pleura.
Changing the tract is usually performed first. This can be done
Figure 3 Line drawing demonstrating areas that should be avoided to
reduce the risk of bleeding. The central dark shaded area is the
by performing a cholangiogram via the old tract and choosing a
central portion of the hilum of the liver that carries a higher risk of different skin entry site and a totally different peripheral bile
injuring arteries and injuring large caliber portal veins. This dark- duct. Another way is to change the skin entry site but choose the
shaded area should be avoided when performing routine PTC, but it same biliary entry site by targeting the same bile duct. Targeting
should be particularly avoided when PBD placement is contem-
plated. The curved arced arrow represents the direction and trajec-
tory of the needle pass to perform a PTC and eventually place a PBD.
As the arced arrow demonstrates, the needle pass should be above
the rib, avoiding the intercostal nerves and vessels that run inferior
to the ribs (asterisks).

sheath and a 10-French PBD with a 9-French vascular sheath.

Contrast is then injected gently through the side port of the
sheath while preserving transhepatic wire access (Fig. 4). If the
sheath is long and its tip is deep and close to or inside the bile
ducts, the operator should pull the sheath back along the tract
while injecting contrast to fully interrogate the tract and expose
possible transgressed vessels. Usually a transgressed portal vein
is revealed (Fig. 4). If only a portal vein is visualized, its site is
identified and the transhepatic PBD is upsized and its side holes
are not placed at the the portal vein transgression site. The up-
sized PBD is then capped for at least 24 to 48 hours. Subsequent
changes of the drain, if feasible, should be avoided for the weeks
to come to encourage healing of the tract.
If there is profuse bleeding and no vessels are detected during
the tractogram, the operator should look for absence of contrast
in the central bile ducts while the intrahepatic peripheral bile
ducts and small bowel are still opacified by contrast (absent
central bile duct sign, coined by authors) (Fig. 5A). This is be-
cause the biliary system is communicating with a high pressure
vessel (an artery). The gentle contrast injection is not powerful
enough to reflux contrast into the artery for it to be opacified. Figure 4 Transhepatic tractogram demonstrating transgression of
However, the high pressure blood retains the contrast up against the portal vein. Fluoroscopic caption during a transhepatic tracto-
the peripheral bile ducts and clears the central bile ducts of gram of a percutaneous biliary drain. Contrast is injected through a
sheath and into the partly matured tract (curved arrows). A portal
contrast driving the contrast down into the bowel (Fig. 5). In this
vein is seen extending upward toward the dome of the liver (arrow-
situation the operator can inject contrast via the sheath more heads). It parallels the bile duct that is also seen from the tractogram
aggressively to reflux back in the arteries to opacify/identify (white arrows). The transhepatic tract of the drain has not com-
them (Figs. 5-7). Furthermore, digital subtraction (digital sub- pletely matured (epithelialized). The last parts of tracts to mature are
traction cholangiography) can be utilized to increase sensitivity areas that traverse vessels and areas where there is shearing motion
of identifying small transgressed vessels (Figs. 5, B-D, 6, 7A). from respiration just outside the liver at the chest wall peritoneal
The operator must have in mind that overly aggressive transhe- junction (black arrows).
Figure 5 Transhepatic tractogram demonstrating transgression of a hepatic artery. (A) Above is a fluoroscopic caption
with an adjacent schematic of it (below). The image was obtained just after a tractogram attempt (injecting contrast
through a transhepatic sheath). The central bile ducts (right main hepatic, common hepatic, and common bile duct)
(arrowheads) are clear of contrast. This is coined by the current authors as an absent central bile duct sign. Contrast has
accumulated down in the small bowel (B). The peripheral intrahepatic bile ducts retain the contrast within them as the
contrast is driven out to the periphery (depicted by black arrows in accompanying schematic) and entrapped under
pressure due to the central bile duct being pressurized by its communication with an artery. (B) Digital subtraction
tractogram/cholangiogram demonstrating the right hepatic artery and its branches (arrowheads). Contrast is also seen
in the bile ducts (white arrows). The black arrow points to the site of an arterioportal fistula (APF), which becomes more
evident in C and D. (C) Digital subtraction tractogram/cholangiogram after B. The contrast is being cleared from the
central bile ducts and is being driven briskly down into the small bowel. The arrowheads point to the portal vein
branches that are a result of the APF noted in B. Notice the subtracted contrast sitting (entrapped and pressurized) in
the bile ducts that run parallel to the portal vein branches. (D) Digital subtraction tractogram/cholangiogram of a
delayed frame after B and C. The contrast is being cleared from the central bile ducts and is being driven briskly down
into the small bowel (depicted by large hollow arrow). The arrowheads point to the peripheral portal vein branches that
are a result of the APF noted in B.
66 W.E.A. Saad, M.G. Davies, and M.D. Darcy

Figure 6 Transhepatic tractogram demonstrating transgression of a hepatic artery. Digital subtraction tractogram/
cholangiogram of another patient (different from Fig. 5). The caption demonstrates the right hepatic artery and its
branches (arrowheads) as well as in the biliary tract and small bowel, B. CHD, common hepatic duct; CD, cystic duct;
CBD, common bile duct.
Bleeding complications 67

Figure 7 Patient with cholangiocarcinoma and a percutaneous transhepatic biliary drain that is bleeding. (A) Digital
subtraction tractogram/cholangiogram demonstrating arterial branches (arrowheads) confirming an arterial injury. The
central bile ducts are filled with clotted blood. The contrast casts around the blood clot giving a tram track appearance
(arrows). (B) Caption from a digital subtraction arteriogram demonstrating no arterial injury. This is the furthermost
right-sided hepatic artery off the celiac axis and only part of the right hepatic lobe is covered by this artery and its
branches. In addition, a faint artery is seen on the angiogram (white arrows). The area of the anastomosis (#) between
the two arteries is noted. (C) Caption from a superselective digital subtraction arteriogram demonstrating no arterial
injury and a clearer view of the faint artery (white arrows) and its anastomotic site (#) with the artery being injected. The
(1) lack of arterial injury by arteriography (which is more sensitive than tractography where the arterial injury is noted),
(2) lack of arterial filling of the periphery of the right hepatic lobe, and (3) faint (indirect) filling of another arterial
branch not seen on a global celiac angiogram all lead the operator to the conclusion that there may be an accessory right
hepatic artery off the superior mesenteric artery (SMA). This anatomic variant occurs in 9 to 26% of people. (D) Caption
from a digital subtraction arteriogram of the SMA demonstrating an accessory right hepatic artery off the SMA. The
arterial branch (arrows) that were seen in B and C) can be seen. In addition, a pseudoaneurysm (arrowhead) can be seen
adjacent to the PBD. The PBD is still in place.
68 W.E.A. Saad, M.G. Davies, and M.D. Darcy

Figure 7 (Cont’d). (E) Caption from a digital subtraction arteriogram of the SMA with the PBD removed over a wire. The
pseudoaneurysm is still noted (arrowhead). In addition, the contrast now runs along the tract of the removed PBD (solid
white arrows) and runs down (directional hollow arrow) the transhepatic tract to the outside of the patient’s body. (F)
Caption from a superselective digital subtraction arteriogram of the accessory right hepatic artery after the operator
crossed over the partly transected artery and coil embolized the distal hepatic artery (arrow). The next stage is to
embolize the pseudoaneurysm (arrowhead) and the partly transected artery proximally. Crossing over and embolizing
distally is important to prevent back filling or back bleeding from adjacent hepatic arteries via intrahepatic arterial
anatomoses as demonstrated in B and C. (G) Fluoroscopic caption after coil embolization of distal hepatic artery (white
arrow), the pseudoaneurysm (arrowhead) and the proximal hepatic artery proximally (black arrow). (H) Caption from
a selective digital subtraction arteriogram of the accessory right hepatic artery after the embolization (the arrow and the
arrowhead correspond with the arrows and the arrowhead of G). The pseudoaneurysm and the bleeding are no longer
visualized.
Figure 8 Liver transplant recipient with bleeding from the percutaneous biliary drain after a traumatic removal of an
endoscopic retrograde cholangiopancreatography (ERCP)-placed plastic endoprosthesis. (A) Fluoroscopic caption
after a transhepatic tractogram/cholangiogram after the patient has undergone a traumatic removal of an ERCP-placed
internal plastic endoprosthesis. A biloma (arrows) has formed due to the traumatic removal of the ERCP stent. (B)
Fluoroscopic caption during an arteriogram of the celiac trunk after the patient has undergone PBD removal and
embolization of the transhepatic tract (arrows). A pseudoaneurysm is now seen at the portahepatis (arrowhead). Before
tract embolization, the arteriograms did not reveal any abnormalities. After tract embolization, the patient continued to
have gastrointestinal bleeding. This led to a repeat arteriogram. (C) Digital subtraction arteriogram (in the same setting
as B) of the celiac trunk after the patient has undergone PBD removal and embolization of the transhepatic tract
(arrows). A pseudoaneurysm is now clearly seen at the portahepatis (arrowhead). (D) Digital subtraction arteriogram
of the celiac trunk after the patient has undergone coil embolization of the pseudoaneurysm (arrowhead). No residual
pseudoaneurysm is seen. Again noted (subtracted out) are the transhepatic tract coils (arrows). (E) Fluoroscopic
caption after placing a new PBD (curved arrow) away from the old tract to drain the bile ducts. Again noted are the coils
in the old transhepatic tract (arrows) and in the pseudoaneurysm (arrowhead).
Figure 9 Patient status after PBD placement with bleeding from the PBD. (A) Selective digital subtraction angiogram
demonstrating an arterioportal fistula (arrowhead). There is a small faint pseudoaneurysm (arrow) that was overlooked
by the operator. (B) Selective digital subtraction angiogram one frame after A, further demonstrating the arterioportal
fistula (arrowhead). Again noted is the small faint pseudoaneurysm (arrow) that was overlooked by the operator. (C)
Selective digital subtraction angiogram after superselective embolization of the involved artery that fed the APF. (D)
Caption from a selective digital subtraction arteriogram with the PBD removed over a wire. The patient had continued
bleeding despite the embolization of the APF in C. The pseudoaneurysm is more prominent (white arrow). In addition,
the contrast now runs along the tract of the removed PBD and runs down (directional hollow black arrow) the
transhepatic tract to the outside of the patient’s body. (E) Unsubtracted fluoroscopic caption from a selective digital
subtraction arteriogram in D with the PBD removed over a wire. The pseudoaneurysm is again noted (white arrow). The
directional hollow black arrow points to the direction of contrast down the transhepatic tract to the outside of the
patient’s body. In addition, the dashed white arrows point to levels at which the artery is partly transected by the PBD.
(F) Digital subtraction arteriogram after embolizing distal to the pseudoaneurysm (white arrows), the pseudoaneurysm
(white arrows), and the proximal arterial portion proximal to the transected artery (arrowhead). (Inset) An unsub-
tracted image showing the coils in the embolized artery, which is outlined by white dashed lines.
Bleeding complications 71

the same bile duct can be aided by targeting a balloon or snare between the hepatic artery and the portal vein. As a result, the
placed at the biliary entry site. hepatic graft is not as forgiving as a native liver and there is a
higher risk for ischemic complications (biliary and/or paren-
chymal).7,8 Ischemic complications may also be encountered,
Hepatic Arteriography and due to the same pathogenesis (lack of reciprocity), in patients
Transcatheter Embolization with advanced cirrhosis and patients with hereditary hemor-
rhagic telangectasia involving the liver.
Once an arterial injury is suspected from the transhepatic trac- When no arterial and no venous injuries are identified and
togram, a hepatic arteriogram is warranted. Some operators may there continues to be bleeding in patients who are not liver
perform an arteriogram first, especially if the patient is unstable. transplant recipients nor cirrhotics, one can contemplate two
Hepatic arteriograms are performed most commonly from a procedures. The first is tract site change and embolizing the old
femoral approach. The celiac axis is catheterized using standard tract (see above) and the second is global or segmental emboli-
5-French catheters such as SOS or C-2 Cobra catheters. If no zation of the hepatic artery using gelfoam to attempt to reduce
bleeding is identified, selective hepatic arteriography is required the perfusion to the liver or to the segment of the liver through
using microcatheters. Selective angiograms should be per- which the PBD passes (Fig. 2). The latter is a rare scenario and
formed with the PBD in place and again after the PBD is removed should be considered as a last line procedure. It is rare because it
over a wire if no bleeding source is identified on the initial is very difficult to have a hemorrhagic PBD complication that
arteriogram.2,5 Careful examination of the arteries in the vicinity forces an operator’s hand to perform a therapeutic procedure
of the transhepatic tract should be performed. Any angiographic without being able to identify a vascular injury. Nevertheless,
abnormality in the arteries adjacent to the percutaneous biliary the option can be entertained in this rare situation (Fig. 2).
drain should be considered the source of bleeding, especially
after a venous injury has been ruled out by a prior tractogram. References
Arterial injuries include active extravasation (Fig. 1), peripheral 1. Venbrux AC, Osterman FA Jr: Percutaneous transhepatic cholangiogra-
arterial truncation, arterial transection (Figs. 7 and 9), pseudoa- phy and percutaneous biliary drainage: Step by step, in LaBerge JM,
neurysms (Figs. 7 and 9), arterioportal fistulae (APF; Figs. 1D, Venbrux AC (eds): Biliary Interventions, Society of CardioVascular In-
5B-D, 9B and C), and, rarely, arteriohepatic vein fistulae6 (Figs. terventional Radiology (SCVIR) Syllabus. Fairfax, VA, Society of Inter-
ventional Radiology, 1995, pp 129-150
1 and 9). Complex injuries can be encountered where several
2. Winick AB, Waybill PN, Venbrux AC: Complications of percutaneous trans-
types of injuries or several sites of arterial injuries are seen6 (Figs. hepatic biliary interventions. Tech Vasc Interv Radiol 4:200-206, 2001
1 and 9). If there is a high suspicion of arterial injury and no 3. Burke DR, Lewis CA, Cardella JF, et al, for the Society of Interventional
arterial injury is identified by the celiac angiogram, a superior Radiology Standards of Practice Committee: Quality improvement
mesenteric arteriogram should be performed to evaluate for an guidelines for percutaneous transhepatic cholangiography and biliary
drainage. J Vasc Interv Radiol 14:S243-S246, 2003
accessory right hepatic artery (Fig. 7). 4. Goodwin SC, Bansal V, Greaser LE, et al: Prevention of hemobilia during
Upon identifying an arterial injury, the involved artery percutaneous biliary drainage: Long-term follow-up. J Vasc Interv Radiol
should be superselectively catheterized and embolized using 8:881-883, 1997
coils. Embolizing the involved hepatic artery should be per- 5. Routh WD, Tatum CM, Lawdahl RB, et al: Tube tamponade: Potential
formed by coiling the artery from distal to proximal across pifall in angiography of arterial hemorrhage associated with percutane-
ous drainage catheters. Radiology 174:945-949, 1990
the injury, if feasible (Figs. 7 and 9).2,7 This prevents back 6. Saad WEA, Davies MG, Ryan CK, et al: Incidence of arterial injuries
bleeding via intrahepatic arterial collaterals. After embolizing detected by angiography following percutaneous right-lobe ultrasound-
an APF, a global arteriogram should be performed to evaluate guided core liver biopsies in human subjects. Am J Gastroenterology
for other APFs that may have been unmasked after emboliz- 101:2641-2645, 2006
ing the main APF that potentially sumped blood away from 7. Saad WEA: Management of nonocclusive hepatic artery complications
after liver tranplantation. Tech Vasc Interv Radiol 10:221-232, 2007
other more minor APFs.7,8 Superselective embolization of the 8. Saad WEA, Davies MG, Rubens DJ, et al: Endoluminal management of
involved hepatic artery is crucial if the patient is a liver trans- arterio-portal fistulae in liver transplant recipients: A single center expe-
plant recipient. Hepatic grafts have an altered reciprocity rience. Vasc Endovasc Surg 40:451-459, 2006