PMC5479965_01
CT examination: coronal pre-contrast image (A); axial arterial (B) and portal (C) phase images. Arrowhead in A shows some large gallstones. After administration of the contrast medium the pseudoaneurysm appeared inside the gallbladder as a round mass with the same density of the arteries (arrows in B e C). Thick and irregular cholecystic walls with inhomogeneous perivisceral fat (asterisks in B e C) suggested us the hypothesis of cholecystitis.
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A Computed Tomography (CT) examination was performed and showed large gallstones [Fig. 1A]. After e.v. administration of the contrast medium a round hypervascular small mass, arising from the cystic artery, appeared inside the gallbladder: it consisted of a pseudoaneurysm [Fig. 1B]. Hypothesis of cholecystitis was suggested by thick and irregular cholecystic walls and inhomogeneous perivisceral fat [Fig. 1C].
This coronal MIP post-processed computed tomography image clearly summarizes the particular vascular anatomy of our patient.. Asterisk shows the pseudoaneurysm of the CA that origin from the lHa; the rHa independently arise from the SM.. CT = celiac trunk; SM = superior mesenteric; IM = inferior mesenteric; S = splenic; lG = left gastric; CHa = common hepatic artery; GD = gastroduodenal; rHa = right hepatic artery; lHa = left hepatic artery; CA = cystic artery.
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Embolization of the pseudoanerysm was achieved using a coaxial system with a 5F Cobra catheter positioned at the origin of the lHa (arrowheads) and a micro-catheter advanced in the CA (arrows). Two micro-coils (asterisk in B) were placed in the neck and lumen of the pseudoanerysm that was finally excluded from circulation. lHa = left hepatic artery; CA = cystic artery.
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Embolization was achieved positioning two micro-coils (VortX-18 Fibered Platinum Coil, Boston Scientific) at the origin of the pseudoneurysm by a micro-catheter (Terumo Progreat microcatheter) [Fig. 3].
After embolization of the pseudoaneurism, a colecistectomy was performed. Gallbladder (A) was fixed by strong adhesions to adiacent tissue and contained the collapsed pseudoanerism mass (B) and large gallstones (C).
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Laparoscopic approach was attempted but it was necessary conversion to laparotomy because strong adhesions hindered the mobilization of the gallbladder [Fig. 4].