PMC4813083_01
(A) Axial maximal intensity projection (MIP) image of the arterial phase acquisition shows three pseudoaneurysms, arising from the anterior and posterior branches of right hepatic artery and the lateral branch of left hepatic artery (black arrows) (B) Volume-rendered image gives three-dimensional overview of the pseudoaneurysms (short white arrows) and arterial anatomy, depicting replaced right hepatic artery (long white arrow) (C) Axial post-contrast venous phase CT image demonstrates multiple cholangitic abscesses in both lobes of liver. The largest one in the left lobe shows pigtail catheter tip within. Black arrow depicts the contrast-filled pseudoaneurysm arising from the right anterior hepatic artery, paralleling the attenuation of aorta
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F1
CTA revealed three contrast-filled outpouchings from hepatic arteries, which followed the attenuation of aorta in venous phase as well, suggestive of pseudoaneurysms [Figure 1].
Digital subtraction angiogram (DSA) images. (A) Selective replaced right hepatic artery DSA shows two pseudoaneurysms, one from a branch of anterior division and the other from a branch of posterior division (black arrows) (B) DSA after coil embolization shows non-filling of the pseudoaneurysms (C) DSA after selective catheterization of the lateral branch of left hepatic artery shows a pseudoaneurysm (black arrow) without any active contrast extravasation (D) DSA of hepatic artery after coil embolization shows non-filling of the pseudoaneurysm
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F2
With these imaging findings, the patient was planned for angiographic embolization [Figure 2].
USG-guided thrombin injection. (A) Gray-scale image shows anechoic pseudoaneurysm arising from the anterior branch of right hepatic artery, which shows yin-yang pattern of color flow within (B) indicating recanalization (C) Shows USG-guided placement of 22G needle tip within the pseudoaneurysm (D) Increased echogenicity within the pseudoaneurysm is observed following thrombin injection and there is absence of color flow, suggestive of complete thrombosis
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F3
Follow-up USG done 24 h later showed recurrence of one of the HAP (arising from the anterior branch of right hepatic artery) [Figure 3]. It was subsequently embolized under USG guidance using 22G Chiba needle, by injecting 2 ml of 100 U/ml concentration human-derived lyophilized thrombin (Floseal; Baxter Healthcare Corporation, Hayward, CA, USA) [Figure 3].