Fig. 1. Initial external biliary drainage catheter.	Fig. 2. Arteriogram with the internal/external drain in place is unremarkable.

Case Reference No. CC-797-07 This 72-year-old man with duodenal adenocarcinoma underwent external biliary drainage (Fig. 1) from the posterior axillary line at an outside hospital. The day after conversion to an internal/external biliary drainage catheter, the patient developed hematobilia. The catheter was exchanged over a guide wire as side-holes were thought to be extending into the liver parenchyma. A second transient episode of moderate intermittent hemobilia occurred 1 day after the drainage catheter had been changed. Hepatic arteriography was performed in multiple projections with the biliary drain in place (Fig. 2) and after the drain had been removed over a guide wire (Fig. 3). The hepatic arteriographic images demonstrated mild narrowing of the right hepatic artery branch which crossed the guide wire in the biliary drain track, but no pseudoaneurysm or extravasation of contrast material. Due to frequent catheter occlusion by blood clot, the biliary drain was later upsized to 16 French. The bleeding resolved. Seven days later and after resolution of his biliary sepsis, two malignant biliary strictures were dilated and treated with stent placement. Because the track was immature, an external biliary drain was left in place. One week later, the patient developed hematemesis. Endoscopy demonstrated bleeding from the ampulla. Hepatic arteriography was again performed, which demonstrated a 1.5-cm pseudoaneurysm (Fig. 4). Microcoil embolization proximal and distal to the pseudoaneurysm neck was performed (Fig. 5). The biliary drain adjacent to the pseudoaneurysm was removed. A new external biliary drain was placed distal to the pseudoaneurysm to allow biliary decompression until clot lysis within the biliary system occurred. The bleeding did not recur. The external biliary drain was removed and the patient has since done well.

Fig. 3. Selective injection into the distal right hepatic artery after removal of the catheter over a guide wire (arrow). Embolization was not performed. Fig. 4. Common hepatic artery injection demonstrates a pseudoaneurysm of the right hepatic artery.   Fig. 5. Common hepatic arterial injection following embolization with 3- and 5-mm microcoils.

Questions 1) With only a minimal narrowing of the hepatic artery, would you have embolized that segment initially given the history, or would you attribute the bleeding to the malignancy causing the common bile duct stricture? 2) If the catheter and guide wire failed to cross the mouth of the pseudoaneurysm into the normal distal hepatic artery and kept entering the pseudoaneurysm, would you use a GDC coil to fill the pseudoaneurysm and then embolize the proximal hepatic artery? 3) Would you choose a new site for biliary drainage after embolizing the pseudoaneurysm?