External Biliary Conduit for Occlusion of an Endobiliary Stent in Malignant Biliary Obstruction: A Nonsurgical Solution

(Nester; Cook) were added to the tract as the sheath was retracted to minimize the risk of bleeding. Neither bleeding nor liver failure were observed after embolization. The patient died 6 months later of systemic metastasis of gastric cancer without any signs of recurrent bleeding from the pseudoaneurysm. In the present case, because of the surgically altered arterial anatomy and vessel injury from previous catheterization, standard antegrade transluminal embolization was considered unsuitable. For coil embolization, the catheter must be advanced adequately into the vicinity of the pseudoaneurysm, but this was impossible because of the extraordinarily tortuous path to the pseudoaneurysm. Embolization with a liquid material such as n-butyl cyanoacrylate posed some risks, including ischemia of the duodenum and pancreas, nontarget embolization of the hepatic artery, and proximal embolization. Percutaneous thrombin injection or coil embolization via direct puncture of the pseudoaneurysm is another treatment choice, but it would have been difficult to detect the pseudoaneurysm under ultrasonographic (US) guidance in this case. A transhepatic arterial approach was thought to be the only way to treat this hepatic hilar pseudoaneurysm fed by tortuous collateral vessels. Previous reports of a transhepatic arterial approach include those of Yu et al (2) and Papadopoulos et al (3), but both groups used a transhepatic arterial approach under US guidance. The present report appears to be the first description of successful treatment via a transhepatic arterial approach under fluoroscopic and angiographic guidance. Yu et al (2) also reported challenges and limitations of percutaneous hepatic arterial puncture paralleling those encountered with other transhepatic interventions, describing the most difficult aspect of the procedure as the actual transhepatic puncture of the desired hepatic artery. Multiple passes are often required, with each pass increasing the risk of hemoperitoneum, hematoma formation, hemobilia, and dissection/pseudoaneurysm of the targeted artery. We performed transhepatic arterial puncture under fluoroscopic and angiographic guidance, allowing easy confirmation of the desired artery. Moreover, we used an axial puncture technique, which is used in percutaneous transhepatic biliary drainage for nondilated bile ducts (4). This technique increases the chance of the puncture needle meeting the targeted vessel because a longer length of puncture site is used, and provides an appropriate angle for insertion of a guide wire. By using this technique, we assumed successful puncture could be obtained with fewer attempts, reducing the risk of multiple passes. In conclusion, transhepatic arterial approach is one treatment option for inaccessible hepatic hilar pseudoaneurysm and should be considered by interventional radiologists when a standard antegrade transarterial approach is impossible.