William D. Routh, MD • Clifton M. Tatum, MD • Richard B. Lawdahl, MD 2 • Josef Misch, MD • Frederick S. Keller, MD
Tube Tamponade: Potential Pitfall in Angiography of Arterial Hemorrhage Associated with Percuta,neous Drainage Catheters' Diagnostic angiography performed to search for a source of hemorrhage in three patients with percutaneous transhepatic biliary catheters and one patient with a percutaneous nephrostomy catheter was initially unrewarding when performed with the drainage catheter in place. In each patient, removal of the drain-. age catheter resulted in severe pulsatile hemorrhage from the parenchymal tract and allowed angiographic localization of the bleeding site. Temporary control of the hemorrhage was then obtained by inflating an angioplasty balloon within the tract. Transcatheter embolotherapy provided definitive control of bleeding in three patients. When initial angiographic evaluation for bleeding in patients with percutaneous biliary and nephrostomy catheters fails to depict a source, the study should be repeated immediately after removal of the drainage catheter. Because hemorrhage can be severe once tamponade is relieved, the drainage catheter should be withdrawn over a guide wire so that a tamponading catheter can be rapidly reinserted to control hemorrhage until more definitive therapy is undertaken.
Index terms: Gastrointestinal tract, angiography, 95.122 • Gastrointestinal tract, hemorrhage, 76.458 • Gastrointestinal tract, interventional procedure, 76.1299 • Kidney, hemorrhage, 81.458 • Kidney, interventional procedure, 81.1299 • Renal angiography, 96.122 Radiology 1990; 174:945-949
interventional radiologic procedures are currently widely used for the diagnosis and treatment of benign and malignant diseases of the biliary and urinary tracts (1,2). Clinically significant hemorrhage, a complication of percutaneous transhepatic biliary drainage (PTBD), percutaneous nephrostomy, and percutaneous nephrostolithotomy (PNL), is relatively infrequent and often self-limited (3-13). In cases of severe, persistent, or recurrent hemorrhage, diagnostic angiography is indicated to define the specific bleeding lesion that often can be definitively treated with transcatheter techniques (5,14,15). The most common angiographic findings in patients with significant arterial hemorrhage after percutaneous drainage procedures are pseudoaneurysms or arteriovenous fistulas (4,11,16-20). Less frequently, hemorrhage may be due to direct arterial injury without formation of a pseudoaneurysm or an arteriovenous fistula. Diagnostic angiography can aid in the detection of both pseudoaneurysms and arteriovenous fistulas, even in the absence of active hemorrhage. However, some direct arterial injuries may be angiographically apparent only during active bleeding by means of visualization of extravasation of contrast material from the site of arterial injury. Therefore, such lesions may be missed if the patient is not actively bleeding at the time of angiography. We have recently encountered four patients in whom the tamponading effect of a drainage catheter present DERCUTANEOUS
1 From the Department of Diagnostic Radiology, Division of Angiography and Interventional Radiology, University of Alabama at Birmingham School of Medicine, 619 S 19th St, Birmingham, AL 35233 (W.D.R., C.M.T., R.B.L., F.S.K.) and Department of Radiology, Oregon Health Sciences University, Portland, Ore (J.R.). Received January 19, 1989; revision requested April 17; revision received May 4; accepted May 7. Address reprint requests to W.D.R. 2 Current address: Greenville Memorial Hospital, Greenville, SC. RSNA, 1990
during initial angiography resulted in failure to detect the bleeding lesion. Relief of the tamponade with removal of the drainage catheter resulted in acute recurrence of bleeding and immediate angiographic documentation of the bleeding site in all four patients. Definitive transcatheter therapy was possible in three patients. These cases are presented to illustrate the potential diagnostic pitfall caused by drainage catheter tamponade in patients who bleed following percutaneous interventional procedures of the biliary or urinary tract and to outline a few simple and safe steps to improve the diagnostic yield from angiography in these patients.
CASE REPORTS Case /.—A 56-year-old man with a stone obstructing the proximal right ureter underwent percutaneous nephrostomy and tract dilation with placement of a 22-F Councill catheter (Bard Urological Division, Covington, Ga). The following day, percutaneous nephrostolithotomy was performed, complicated by perforation of the proximal right ureter. A follow-up nephrostogram obtained 5 days later showed a blood clot in the right renal pelvis and a functioning double-pigtail right ureteral stent. Three days later he developed acute pain in the right flank with occlusion of the nephrostomy catheter by clotted blood. A selective right renal angiogram obtained with the nephrostomy catheter in place failed to depict a bleeding lesion (Fig la). When the nephrostomy catheter was removed over a guide wire, there was brisk, pulsatile bleeding through the nephrostomy tract (Fig lb, 1c). A repeat renal angiogram showed marked extravasation of contrast material from a lacerated segmental renal artery, with dense opacification of the tract. Hemorrhage was acutely controlled by inflation of a 10-mm-diame-
Abbreviations: PTBD = percutaneous transhepatic biliary drainage, PNL = percutaneous nephrostolithotomy.
945
ter angioplasty balloon within the tract and definitively treated with subselective embolization of the injured vessel with 0.5 mL 3 of absolute ethanol and a single large particle of absorbable gelatin sponge. Hemorrhage did not recur when the nephrostomy catheter was removed 6 days after embolization. A repeat arteriogram obtained at that time showed an occluded intrarenal branch artery with segmental infarction in the midportion of the right kidney (Fig 1d). At 8 months follow-up, there has been no recurrence of the bleeding and no evidence of hypertension. Case 2.—A 68-year-old man underwent PTBD for relief of obstruction of the common bile duct caused by carcinoma of the pancreatic head. Immediately after the procedure, there was bloody drainage through the biliary catheter. Celiac angiography was performed 2 days later with the drainage catheter in place because of persistent hemobilia, and no evidence of a bleeding site was detected (Fig 2a). The drainage catheter was then removed over a guide wire, and repeat celiac angiography showed marked extravasation of contrast material from a branch of the right hepatic artery into the transhepatic catheter tract (Fig 2b). The right hepatic artery was occluded with coil springs just proximal to the bleeding site, resulting in cessation of hemorrhage (Fig 2c). The biliary drainage catheter was then replaced, and bleeding did not recur. Case 3.—A 59-year-old man presented with hematemesis and melena 8 months after PTBD was performed for obstructive jaundice due to gastric carcinoma metastatic to porta hepatis lymph nodes. Esophagogastroduodenoscopy showed fresh blood in the afferent jejunal limb of the gastrojejunostomy but no specific bleeding site. Emergency celiac, left gastric, and superior mesenteric angiography also failed to depict a cause of the bleeding. Gastrointestinal bleeding recurred 1 week later. This time, fresh blood was aspirated from the biliary drainage catheter. Angiography was repeated electively when the patient was not actively bleeding. Hepatic angiography with the drainage catheter in place again failed to depict a bleeding site (Fig 3a). Removal of the biliary drainage catheter over a guide wire resulted in brisk, pulsatile arterial bleeding through the transhepatic tract. A second hepatic arteriogram showed marked extravasation of contrast material from the proper hepatic artery with opacification of the adjacent biliary tree, findings indicative of a fistula between the proper hepatic artery and common hepatic duct (Fig 3b). Bleeding was temporarily controlled with a 6-mm-diameter angioplasty balloon inflated in the transhepatic tract, which allowed successful occlusion with a coil spring of the proper hepatic artery immediately proximal to the site of the fistula. Follow-up angiography with the balloon removed from the tract showed no further bleeding. The patient died of a pulmonary embolus several days later. At autopsy, erosion due to extensive meta946 • Radiology
a.
c d. Figure 1. Case 1. (a) Initial right renal arteriogram, obtained with a 22-F nephrostomy catheter in place, does not demonstrate acute hemorrhage, pseudoaneurysm, or arteriovenous fistula. Early (b) and later (c) repeat right renal arteriograms after removal of the nephrostomy catheter over a guide wire reveal marked extravasation of contrast material into the nephrostomy tract (arrowheads). (d) Right renal arteriogram obtained 6 days after embolization of the bleeding artery shows abrupt occlusion of a segmental artery (arrowhead) with a zone of decreased perfusion in the midportion of the right kidney. .
static carcinoma in the porta hepatis had created the fistulous communication between the proper hepatic artery and adjacent bile duct. The proper hepatic artery remained occluded by a coil spring and thrombus at the site of the fistula. Case 4.—A 65-year-old man with obstruction of the common bile duct due to pancreatic carcinoma underwent retrograde endoscopic placement of a biliary endoprosthesis. Ten months later, occlusion of this stent, complicated by cholangitis, necessitated percutaneous transhepatic biliary drainage. Because of extensive duodenal invasion by tumor, a long 16-F external-internal stent was positioned with its distal end in the proximal
jejunum. Four months later, the patient had fever, melena, and a small amount of hematemesis. Bloody bile was aspirated through the external limb of the biliary stent. An arteriogram of the common hepatic artery revealed marked irregularity of the gastroduodenal and hepatic arteries due to extensive tumor encasement but no definite bleeding site (Fig 4a). The biliary stent was removed over a guide wire, resulting in brisk arterial bleeding through the transhepatic tract (Fig 4b). Hepatic angiography was immediately repeated and showed a fistula between the proper hepatic artery and common hepatic duct, with marked extravasation of contrast material into the biliary tree and March 1990 • Part 2
b. c Figure 2. Case 2. (a) Initial celiac arteriogram, obtained with transhepatic biliary drainage catheter in place, reveals no evidence of acute hemorrhage. Encasement of the gastroduodenal artery (arrow) from pancreatic carcinoma is evident. (b) Repeat celiac arteriogram, with the biliary drainage catheter removed over a guide wire, demonstrates acute extravasation of contrast material (large arrowhead) from an artery in the right lobe of the liver, with contrast material running out the catheter tract (small arrowheads). (c) Proper hepatic arteriogram obtained after embolization shows occlusion of the right hepatic artery with coil springs (arrow) and no further evidence of acute bleeding. a
.
.
a.
b. Figure 3. Case 3. (a) Initial hepatic arteriogram, obtained with biliary drainage catheter in place, shows tortuosity of right lobe arteries with some stretching of left lobe branches. There is no evidence of active bleeding. (b) After removal of the biliary catheter over a guide wire, massive hemorrhage is demonstrated by extravasation of contrast material (arrowheads) into the biliary system, out the catheter tract, and onto the sterile drapes at the site of biliary tube insertion.
transhepatic catheter track. A 10-mm-diameter angioplasty balloon was inflated in the transhepatic tract for acute control of hemorrhage. Superior mesenteric pharmacoangiography after intraarterial administration of tolazaline hydrochloride subsequently demonstrated occlusion of the portal vein. Because of the high risk that hepatic necrosis would develop if the proper hepatic artery were occluded in the presence of portal vein occlusion, embolization was not performed. An 18-F biliary stent devoid of Volume 174 • Number 3 • Part 2
intrahepatic side holes was left in place to limit further blood loss. The patient died
9 days later. An autopsy was not performed.
DISCUSSION
Severe bleeding has been noted in 3%-6% of patients after PTBD, and hemorrhage requiring blood transfusion after PNL has been reported in 2%-11% of patients (3-5,7,9,12). The
risk of significant bleeding after percutaneous nephrostomy appears to be significantly less (13). In patients in whom bleeding occurs within days to weeks after initial placement of a drainage tube, the most likely mechanism of vascular injury is arterial trauma caused by the initial puncture or tract dilation (5). In cases of delayed bleeding after PTBD, other factors may contribute to bleeding, such as mycotic arteritis Radiology • 947
a. b. Figure 4. Case 4. (a) Hepatic angiogram, obtained with faintly radiopaque biliary drainage catheter (arrows) in place, demonstrates marked encasement of the common and proper hepatic and gastroduodenal arteries from pancreatic carcinoma. There is no evidence of acute bleeding. (b) After removal of the biliary catheter over a guide wire, repeat hepatic arteriography reveals marked extravasation of contrast material (arrowheads) out the tube tract and onto the sterile drapes at the site of biliary tube insertion.
secondary to chronic infection, pressure erosion by the tube, trauma of multiple tube changes, progression of liver disease, or development of coagulopathy (5). Also, as illustrated in cases 3 and 4, direct tumor involvement of an adjacent bile duct and hepatic artery can result in an arterial-biliary fistula. Early minor bleeding is usually self-limited and can be managed by frequent catheter flushing to prevent catheter occlusion by clot. If the side holes of a PTBD catheter are within the liver parenchyma, merely adjusting the catheter position will usually suffice to control bleeding. When bleeding occurs after catheter removal or exchange, replacement with a larger catheter will often tamponade the bleeding site (5,14,15,21-23). Alternatively, an angioplasty balloon inflated in the parenchymal tract can be used. This tamponading effect of a drainage catheter or angioplasty balloon has been described by various authors for short-term control of hemorrhage due to PTBD or PNL (5,14-16,21,23). Although tamponade may provide lasting control of bleeding in some patients, recurrent, severe, or persistent bleeding warrants angiographic evaluation in others. A pseudoaneurysm or arteriovenous fistula will 948 • Radiology
most commonly be found (4,14,15). Less frequently, bleeding may be due to an arterial laceration or erosion existing without an associated pseudoaneurysm or arteriovenous fistula. In such cases, the only definitive angiographic finding may be extravasation of contrast material from the injured vessel into the parenchymal track or adjacent biliary or urinary track. Extravasation will obviously not be detected if bleeding is not ongoing at the time of angiography. Therefore, by temporarily controlling hemorrhage, the tamponading effect of an existing drainage catheter may result in a falsely negative angiographic examination. This phenomenon was initially observed in all four of our cases. Temporary relief of the tamponade by removing the drainage catheter reactivated bleeding and resulted in a positive study in each case. Tube cholangiography in patients with hemobilia will often show retained intraductal thrombus and biliary dilatation due to obstruction of the drainage catheter by blood clot. We postulate that the absence of such findings in our cases may have been due to the presence of patent biliary stents at the time of angiography in these patients in whom bleeding had been intermittent and the biliary
tracts had been adequately drained. In each case, angiography was performed immediately after reactivation of acute hemorrhage; thus, insufficient time was allowed for clotting to occur. Since arterial bleeding after removal of a biliary or nephrostomy tube may be severe, blood should be immediately available for transfusion and the patient's hemodynamic status should be continually monitored. A means of rapidly controlling hemorrhage during diagnostic angiography is essential. Replacing the drainage catheter with one of the same size may not be effective, and attempts at insertion of an oversized catheter may result in undue delay and continued blood loss. A simple, safe, and effective alternative is initial exchange of the drainage catheter over a guide wire for an angioplasty catheter with an inflated balloon of appropriate length and diameter to occlude and tamponade the arterial lesion. The balloon can then be briefly deflated and reinflated as necessary during the angiographic procedure to facilitate diagnosis and transcatheter embolotherapy while blood loss is minimized. After successful embolization of the lacerated vessel, the angioplasty catheter can then be replaced with an appropriate drainMarch 1990 • Part 2
age catheter, until discontinuation of biliary or nephrostomy drainage is deemed to be clinically indicated. n References 1. Ring EJ, Kerlan RK Jr. Interventional biliary radiology. AJR 1984; 142:31-34. 2. Castaneda-Zuniga WR, Clayman R, Smith A, Rusnak B, Herrera M, Amplatz K. Nephrostolithotomy: percutaneous techniques for urinary calculus removal. AJR 1982; 139:721-726. 3. Mueller PR, vonSonnenberg E, Ferrucci JT Jr. Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures. AJR 1982; 138:17-23. 4. Monden M, Okamura J, Kobayashi N, et al. Hemobilia after percutaneous transhepatic biliary drainage. Arch Surg 1980; 115:161-164. 5. Mitchell SE, Shuman LS, Ka'ufman SL, et al. Biliary catheter drainage complicated by hemobilia: treatment by balloon embolotherapy. Radiology 1985; 157:645-652. 6. Wickham JEA, Kellett MJ, Miller RA. Elective percutaneous nephrolithotomy in 50 patients: an analysis of the technique, results and complications. J Urol 1983; 129:904-906. 7. Reddy PK, Hulbert JC, Lange PH, et al. Percutaneous removal of renal and ureter-
Volume 174 • Number 3 • Part 2
al calculi: experience with 400 cases. J Urol 1985; 134:662-665. 8. Clayman RV, Surya V, Miller RP, et al. Percutaneous nephrolithotomy: extraction of renal and ureteral calculi from 100 patients. J Urol 1984; 131:868-871. 9. Lee WJ, Loh G, Smith AD, White E, et al. Percutaneous extraction of renal stones: experience in 100 patients. AIR 1985; 144:457-462. 10. Lang EK. Percutaneous nephrostolithotomy and lithotripsy: a multi-institutional survey of complications. Radiology 1987; 162:25-30. 11. Lee WJ, Smith AD, Cubelli V, et al. Complications of percutaneous nephrolithotomy. AJR 1987; 148:177-180. 12. Dunnick NR, Carson CC, Braun SD, et al. Complications of percutaneous nephrostolithotomy. Radiology 1985; 157:51-55. 13. Stables DP, Ginsberg NJ, Johnson ML. Percutaneous nephrostomy: a series and review of the literature. AIR 1978; 130:7582. 14. ROsch I, Putnam JS, Keller FS. Diagnosis and management of hemobilia. Semin Intervent Radiol 1988; 5:49-60. 15. Patterson DE, Segura JW, LeRoy AJ, Benson RC Jr, May G. The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J Urol 1985; 133:447-451. 16. Clayman RV, Surya V, Hunter D, et al. Renal vascular complications associated
with the percutaneous removal of renal calculi. J Urol 1984; 132:228-230. 17. Hoevels J, Nilsson U. Intrahepatic vascular lesions following nonsurgical percutaneous transhepatic bile duct intubation. Gastrointest Radiol 1980; 5:127-135. 18. Wagner WH, Lundell CJ, Donovan AJ. Percutaneous angiographic embolization for hepatic arterial hemorrhage. Arch Surg 1985; 120:1241-1249. 19. Cope C, Zeit RM. Pseudoaneurysms after nephrostomy. AJR 1982; 139:255-261. 20. Vaughan R, ROsch J, Keller FS, Antonovic R. Treatment of hemobilia by transcatheter vascular occlusion. Eur J Radiol 1984; 4:183-189. 21. Sarr MG, Kaufman SL, Zuidema GD, Cameron JL. Management of hemobilia associated with transhepatic internal biliary drainage catheters. Surgery 1984; 95:603607. 22. Rosen RJ, Rothberg M. Transhepatic embolization of hepatic artery pseudoaneurysm following biliary drainage. Radiology 1982; 145:532-533. 23. Sniderman KW, Morse SS, Rapoport S, Ross GR. Hemobilia following transhepatic biliary drainage: occlusion of an hepatoportal fistula by balloon tamponade. Radiology 1985; 154:827.
Radiology • 949
Tube Tamponade: Potential Pitfall in Angiography of Arterial Hemorrhage Associated with Percuta,neous Drainage Catheters' Diagnostic angiography performed to search for a source of hemorrhage in three patients with percutaneous transhepatic biliary catheters and one patient with a percutaneous nephrostomy catheter was initially unrewarding when performed with the drainage catheter in place. In each patient, removal of the drain-. age catheter resulted in severe pulsatile hemorrhage from the parenchymal tract and allowed angiographic localization of the bleeding site. Temporary control of the hemorrhage was then obtained by inflating an angioplasty balloon within the tract. Transcatheter embolotherapy provided definitive control of bleeding in three patients. When initial angiographic evaluation for bleeding in patients with percutaneous biliary and nephrostomy catheters fails to depict a source, the study should be repeated immediately after removal of the drainage catheter. Because hemorrhage can be severe once tamponade is relieved, the drainage catheter should be withdrawn over a guide wire so that a tamponading catheter can be rapidly reinserted to control hemorrhage until more definitive therapy is undertaken.
Index terms: Gastrointestinal tract, angiography, 95.122 • Gastrointestinal tract, hemorrhage, 76.458 • Gastrointestinal tract, interventional procedure, 76.1299 • Kidney, hemorrhage, 81.458 • Kidney, interventional procedure, 81.1299 • Renal angiography, 96.122 Radiology 1990; 174:945-949
interventional radiologic procedures are currently widely used for the diagnosis and treatment of benign and malignant diseases of the biliary and urinary tracts (1,2). Clinically significant hemorrhage, a complication of percutaneous transhepatic biliary drainage (PTBD), percutaneous nephrostomy, and percutaneous nephrostolithotomy (PNL), is relatively infrequent and often self-limited (3-13). In cases of severe, persistent, or recurrent hemorrhage, diagnostic angiography is indicated to define the specific bleeding lesion that often can be definitively treated with transcatheter techniques (5,14,15). The most common angiographic findings in patients with significant arterial hemorrhage after percutaneous drainage procedures are pseudoaneurysms or arteriovenous fistulas (4,11,16-20). Less frequently, hemorrhage may be due to direct arterial injury without formation of a pseudoaneurysm or an arteriovenous fistula. Diagnostic angiography can aid in the detection of both pseudoaneurysms and arteriovenous fistulas, even in the absence of active hemorrhage. However, some direct arterial injuries may be angiographically apparent only during active bleeding by means of visualization of extravasation of contrast material from the site of arterial injury. Therefore, such lesions may be missed if the patient is not actively bleeding at the time of angiography. We have recently encountered four patients in whom the tamponading effect of a drainage catheter present DERCUTANEOUS
1 From the Department of Diagnostic Radiology, Division of Angiography and Interventional Radiology, University of Alabama at Birmingham School of Medicine, 619 S 19th St, Birmingham, AL 35233 (W.D.R., C.M.T., R.B.L., F.S.K.) and Department of Radiology, Oregon Health Sciences University, Portland, Ore (J.R.). Received January 19, 1989; revision requested April 17; revision received May 4; accepted May 7. Address reprint requests to W.D.R. 2 Current address: Greenville Memorial Hospital, Greenville, SC. RSNA, 1990
during initial angiography resulted in failure to detect the bleeding lesion. Relief of the tamponade with removal of the drainage catheter resulted in acute recurrence of bleeding and immediate angiographic documentation of the bleeding site in all four patients. Definitive transcatheter therapy was possible in three patients. These cases are presented to illustrate the potential diagnostic pitfall caused by drainage catheter tamponade in patients who bleed following percutaneous interventional procedures of the biliary or urinary tract and to outline a few simple and safe steps to improve the diagnostic yield from angiography in these patients.
CASE REPORTS Case /.—A 56-year-old man with a stone obstructing the proximal right ureter underwent percutaneous nephrostomy and tract dilation with placement of a 22-F Councill catheter (Bard Urological Division, Covington, Ga). The following day, percutaneous nephrostolithotomy was performed, complicated by perforation of the proximal right ureter. A follow-up nephrostogram obtained 5 days later showed a blood clot in the right renal pelvis and a functioning double-pigtail right ureteral stent. Three days later he developed acute pain in the right flank with occlusion of the nephrostomy catheter by clotted blood. A selective right renal angiogram obtained with the nephrostomy catheter in place failed to depict a bleeding lesion (Fig la). When the nephrostomy catheter was removed over a guide wire, there was brisk, pulsatile bleeding through the nephrostomy tract (Fig lb, 1c). A repeat renal angiogram showed marked extravasation of contrast material from a lacerated segmental renal artery, with dense opacification of the tract. Hemorrhage was acutely controlled by inflation of a 10-mm-diame-
Abbreviations: PTBD = percutaneous transhepatic biliary drainage, PNL = percutaneous nephrostolithotomy.
945
ter angioplasty balloon within the tract and definitively treated with subselective embolization of the injured vessel with 0.5 mL 3 of absolute ethanol and a single large particle of absorbable gelatin sponge. Hemorrhage did not recur when the nephrostomy catheter was removed 6 days after embolization. A repeat arteriogram obtained at that time showed an occluded intrarenal branch artery with segmental infarction in the midportion of the right kidney (Fig 1d). At 8 months follow-up, there has been no recurrence of the bleeding and no evidence of hypertension. Case 2.—A 68-year-old man underwent PTBD for relief of obstruction of the common bile duct caused by carcinoma of the pancreatic head. Immediately after the procedure, there was bloody drainage through the biliary catheter. Celiac angiography was performed 2 days later with the drainage catheter in place because of persistent hemobilia, and no evidence of a bleeding site was detected (Fig 2a). The drainage catheter was then removed over a guide wire, and repeat celiac angiography showed marked extravasation of contrast material from a branch of the right hepatic artery into the transhepatic catheter tract (Fig 2b). The right hepatic artery was occluded with coil springs just proximal to the bleeding site, resulting in cessation of hemorrhage (Fig 2c). The biliary drainage catheter was then replaced, and bleeding did not recur. Case 3.—A 59-year-old man presented with hematemesis and melena 8 months after PTBD was performed for obstructive jaundice due to gastric carcinoma metastatic to porta hepatis lymph nodes. Esophagogastroduodenoscopy showed fresh blood in the afferent jejunal limb of the gastrojejunostomy but no specific bleeding site. Emergency celiac, left gastric, and superior mesenteric angiography also failed to depict a cause of the bleeding. Gastrointestinal bleeding recurred 1 week later. This time, fresh blood was aspirated from the biliary drainage catheter. Angiography was repeated electively when the patient was not actively bleeding. Hepatic angiography with the drainage catheter in place again failed to depict a bleeding site (Fig 3a). Removal of the biliary drainage catheter over a guide wire resulted in brisk, pulsatile arterial bleeding through the transhepatic tract. A second hepatic arteriogram showed marked extravasation of contrast material from the proper hepatic artery with opacification of the adjacent biliary tree, findings indicative of a fistula between the proper hepatic artery and common hepatic duct (Fig 3b). Bleeding was temporarily controlled with a 6-mm-diameter angioplasty balloon inflated in the transhepatic tract, which allowed successful occlusion with a coil spring of the proper hepatic artery immediately proximal to the site of the fistula. Follow-up angiography with the balloon removed from the tract showed no further bleeding. The patient died of a pulmonary embolus several days later. At autopsy, erosion due to extensive meta946 • Radiology
a.
c d. Figure 1. Case 1. (a) Initial right renal arteriogram, obtained with a 22-F nephrostomy catheter in place, does not demonstrate acute hemorrhage, pseudoaneurysm, or arteriovenous fistula. Early (b) and later (c) repeat right renal arteriograms after removal of the nephrostomy catheter over a guide wire reveal marked extravasation of contrast material into the nephrostomy tract (arrowheads). (d) Right renal arteriogram obtained 6 days after embolization of the bleeding artery shows abrupt occlusion of a segmental artery (arrowhead) with a zone of decreased perfusion in the midportion of the right kidney. .
static carcinoma in the porta hepatis had created the fistulous communication between the proper hepatic artery and adjacent bile duct. The proper hepatic artery remained occluded by a coil spring and thrombus at the site of the fistula. Case 4.—A 65-year-old man with obstruction of the common bile duct due to pancreatic carcinoma underwent retrograde endoscopic placement of a biliary endoprosthesis. Ten months later, occlusion of this stent, complicated by cholangitis, necessitated percutaneous transhepatic biliary drainage. Because of extensive duodenal invasion by tumor, a long 16-F external-internal stent was positioned with its distal end in the proximal
jejunum. Four months later, the patient had fever, melena, and a small amount of hematemesis. Bloody bile was aspirated through the external limb of the biliary stent. An arteriogram of the common hepatic artery revealed marked irregularity of the gastroduodenal and hepatic arteries due to extensive tumor encasement but no definite bleeding site (Fig 4a). The biliary stent was removed over a guide wire, resulting in brisk arterial bleeding through the transhepatic tract (Fig 4b). Hepatic angiography was immediately repeated and showed a fistula between the proper hepatic artery and common hepatic duct, with marked extravasation of contrast material into the biliary tree and March 1990 • Part 2
b. c Figure 2. Case 2. (a) Initial celiac arteriogram, obtained with transhepatic biliary drainage catheter in place, reveals no evidence of acute hemorrhage. Encasement of the gastroduodenal artery (arrow) from pancreatic carcinoma is evident. (b) Repeat celiac arteriogram, with the biliary drainage catheter removed over a guide wire, demonstrates acute extravasation of contrast material (large arrowhead) from an artery in the right lobe of the liver, with contrast material running out the catheter tract (small arrowheads). (c) Proper hepatic arteriogram obtained after embolization shows occlusion of the right hepatic artery with coil springs (arrow) and no further evidence of acute bleeding. a
.
.
a.
b. Figure 3. Case 3. (a) Initial hepatic arteriogram, obtained with biliary drainage catheter in place, shows tortuosity of right lobe arteries with some stretching of left lobe branches. There is no evidence of active bleeding. (b) After removal of the biliary catheter over a guide wire, massive hemorrhage is demonstrated by extravasation of contrast material (arrowheads) into the biliary system, out the catheter tract, and onto the sterile drapes at the site of biliary tube insertion.
transhepatic catheter track. A 10-mm-diameter angioplasty balloon was inflated in the transhepatic tract for acute control of hemorrhage. Superior mesenteric pharmacoangiography after intraarterial administration of tolazaline hydrochloride subsequently demonstrated occlusion of the portal vein. Because of the high risk that hepatic necrosis would develop if the proper hepatic artery were occluded in the presence of portal vein occlusion, embolization was not performed. An 18-F biliary stent devoid of Volume 174 • Number 3 • Part 2
intrahepatic side holes was left in place to limit further blood loss. The patient died
9 days later. An autopsy was not performed.
DISCUSSION
Severe bleeding has been noted in 3%-6% of patients after PTBD, and hemorrhage requiring blood transfusion after PNL has been reported in 2%-11% of patients (3-5,7,9,12). The
risk of significant bleeding after percutaneous nephrostomy appears to be significantly less (13). In patients in whom bleeding occurs within days to weeks after initial placement of a drainage tube, the most likely mechanism of vascular injury is arterial trauma caused by the initial puncture or tract dilation (5). In cases of delayed bleeding after PTBD, other factors may contribute to bleeding, such as mycotic arteritis Radiology • 947
a. b. Figure 4. Case 4. (a) Hepatic angiogram, obtained with faintly radiopaque biliary drainage catheter (arrows) in place, demonstrates marked encasement of the common and proper hepatic and gastroduodenal arteries from pancreatic carcinoma. There is no evidence of acute bleeding. (b) After removal of the biliary catheter over a guide wire, repeat hepatic arteriography reveals marked extravasation of contrast material (arrowheads) out the tube tract and onto the sterile drapes at the site of biliary tube insertion.
secondary to chronic infection, pressure erosion by the tube, trauma of multiple tube changes, progression of liver disease, or development of coagulopathy (5). Also, as illustrated in cases 3 and 4, direct tumor involvement of an adjacent bile duct and hepatic artery can result in an arterial-biliary fistula. Early minor bleeding is usually self-limited and can be managed by frequent catheter flushing to prevent catheter occlusion by clot. If the side holes of a PTBD catheter are within the liver parenchyma, merely adjusting the catheter position will usually suffice to control bleeding. When bleeding occurs after catheter removal or exchange, replacement with a larger catheter will often tamponade the bleeding site (5,14,15,21-23). Alternatively, an angioplasty balloon inflated in the parenchymal tract can be used. This tamponading effect of a drainage catheter or angioplasty balloon has been described by various authors for short-term control of hemorrhage due to PTBD or PNL (5,14-16,21,23). Although tamponade may provide lasting control of bleeding in some patients, recurrent, severe, or persistent bleeding warrants angiographic evaluation in others. A pseudoaneurysm or arteriovenous fistula will 948 • Radiology
most commonly be found (4,14,15). Less frequently, bleeding may be due to an arterial laceration or erosion existing without an associated pseudoaneurysm or arteriovenous fistula. In such cases, the only definitive angiographic finding may be extravasation of contrast material from the injured vessel into the parenchymal track or adjacent biliary or urinary track. Extravasation will obviously not be detected if bleeding is not ongoing at the time of angiography. Therefore, by temporarily controlling hemorrhage, the tamponading effect of an existing drainage catheter may result in a falsely negative angiographic examination. This phenomenon was initially observed in all four of our cases. Temporary relief of the tamponade by removing the drainage catheter reactivated bleeding and resulted in a positive study in each case. Tube cholangiography in patients with hemobilia will often show retained intraductal thrombus and biliary dilatation due to obstruction of the drainage catheter by blood clot. We postulate that the absence of such findings in our cases may have been due to the presence of patent biliary stents at the time of angiography in these patients in whom bleeding had been intermittent and the biliary
tracts had been adequately drained. In each case, angiography was performed immediately after reactivation of acute hemorrhage; thus, insufficient time was allowed for clotting to occur. Since arterial bleeding after removal of a biliary or nephrostomy tube may be severe, blood should be immediately available for transfusion and the patient's hemodynamic status should be continually monitored. A means of rapidly controlling hemorrhage during diagnostic angiography is essential. Replacing the drainage catheter with one of the same size may not be effective, and attempts at insertion of an oversized catheter may result in undue delay and continued blood loss. A simple, safe, and effective alternative is initial exchange of the drainage catheter over a guide wire for an angioplasty catheter with an inflated balloon of appropriate length and diameter to occlude and tamponade the arterial lesion. The balloon can then be briefly deflated and reinflated as necessary during the angiographic procedure to facilitate diagnosis and transcatheter embolotherapy while blood loss is minimized. After successful embolization of the lacerated vessel, the angioplasty catheter can then be replaced with an appropriate drainMarch 1990 • Part 2
age catheter, until discontinuation of biliary or nephrostomy drainage is deemed to be clinically indicated. n References 1. Ring EJ, Kerlan RK Jr. Interventional biliary radiology. AJR 1984; 142:31-34. 2. Castaneda-Zuniga WR, Clayman R, Smith A, Rusnak B, Herrera M, Amplatz K. Nephrostolithotomy: percutaneous techniques for urinary calculus removal. AJR 1982; 139:721-726. 3. Mueller PR, vonSonnenberg E, Ferrucci JT Jr. Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures. AJR 1982; 138:17-23. 4. Monden M, Okamura J, Kobayashi N, et al. Hemobilia after percutaneous transhepatic biliary drainage. Arch Surg 1980; 115:161-164. 5. Mitchell SE, Shuman LS, Ka'ufman SL, et al. Biliary catheter drainage complicated by hemobilia: treatment by balloon embolotherapy. Radiology 1985; 157:645-652. 6. Wickham JEA, Kellett MJ, Miller RA. Elective percutaneous nephrolithotomy in 50 patients: an analysis of the technique, results and complications. J Urol 1983; 129:904-906. 7. Reddy PK, Hulbert JC, Lange PH, et al. Percutaneous removal of renal and ureter-
Volume 174 • Number 3 • Part 2
al calculi: experience with 400 cases. J Urol 1985; 134:662-665. 8. Clayman RV, Surya V, Miller RP, et al. Percutaneous nephrolithotomy: extraction of renal and ureteral calculi from 100 patients. J Urol 1984; 131:868-871. 9. Lee WJ, Loh G, Smith AD, White E, et al. Percutaneous extraction of renal stones: experience in 100 patients. AIR 1985; 144:457-462. 10. Lang EK. Percutaneous nephrostolithotomy and lithotripsy: a multi-institutional survey of complications. Radiology 1987; 162:25-30. 11. Lee WJ, Smith AD, Cubelli V, et al. Complications of percutaneous nephrolithotomy. AJR 1987; 148:177-180. 12. Dunnick NR, Carson CC, Braun SD, et al. Complications of percutaneous nephrostolithotomy. Radiology 1985; 157:51-55. 13. Stables DP, Ginsberg NJ, Johnson ML. Percutaneous nephrostomy: a series and review of the literature. AIR 1978; 130:7582. 14. ROsch I, Putnam JS, Keller FS. Diagnosis and management of hemobilia. Semin Intervent Radiol 1988; 5:49-60. 15. Patterson DE, Segura JW, LeRoy AJ, Benson RC Jr, May G. The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J Urol 1985; 133:447-451. 16. Clayman RV, Surya V, Hunter D, et al. Renal vascular complications associated
with the percutaneous removal of renal calculi. J Urol 1984; 132:228-230. 17. Hoevels J, Nilsson U. Intrahepatic vascular lesions following nonsurgical percutaneous transhepatic bile duct intubation. Gastrointest Radiol 1980; 5:127-135. 18. Wagner WH, Lundell CJ, Donovan AJ. Percutaneous angiographic embolization for hepatic arterial hemorrhage. Arch Surg 1985; 120:1241-1249. 19. Cope C, Zeit RM. Pseudoaneurysms after nephrostomy. AJR 1982; 139:255-261. 20. Vaughan R, ROsch J, Keller FS, Antonovic R. Treatment of hemobilia by transcatheter vascular occlusion. Eur J Radiol 1984; 4:183-189. 21. Sarr MG, Kaufman SL, Zuidema GD, Cameron JL. Management of hemobilia associated with transhepatic internal biliary drainage catheters. Surgery 1984; 95:603607. 22. Rosen RJ, Rothberg M. Transhepatic embolization of hepatic artery pseudoaneurysm following biliary drainage. Radiology 1982; 145:532-533. 23. Sniderman KW, Morse SS, Rapoport S, Ross GR. Hemobilia following transhepatic biliary drainage: occlusion of an hepatoportal fistula by balloon tamponade. Radiology 1985; 154:827.
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