MM CONFERENCE (MAR – APR)

HN Procedure MM

115606/64 Hepatic mass biopsy Hepatic artery injury

115621/51 Hepatic parenchymal biopsy Hepatic artery injury

51695/28 ESRD, PERM insertion Subclavian artery injury

21073/65 GDA PsA embolization Non-target embolization

4731/62 Hepatic hilar mass biopsy Right IMA injury

 MM CONFERENCE (MAR – APR)
HN Procedure MM

67273/55 Renal biopsy Post-biopsy bleeding

MM conference
F1 Tikumporn
CASE 1 : นาย สxx ทxx 115606/64
Hepatic artery injury
after liver mass biopsy
+ A 77-year old male patient
+ U/D CA prostate with incidental found liver mass from
MRI of prostate gland.
+ T2DM, HTN, CKD (stage V no RRT)
CASE 1 : Hepatic artery injury
+ Current medication
- No antiplatelet or anticoagulant
+ Lab investigation
Pre-op (19/4) Plt 140k INR 1.04 Cr 3.7 (eGFR 14-25)
MRI upper abdomen 18/3/65
T1W T2W Post-Gd 30s Post-Gd 60s

DWI (B=1000) ADC Post-Gd 90s Post-Gd 270s

MRI upper abdomen 18/3/65

T2W Post-Gd
MRI upper abdomen 18/3/65

Results (from other hospital)

- Suspected intraluminal enhancing soft tissue lesion at periphery of the
questionable right IHD dilatation at hepatic segment 7/6, showing
lowT1, highT2, restricted diffusion, measured about 2.3x1.2 cm, with
associated periphery focal ductal dilatation

Impression:
- DDx Primary tumor : IPNB and CCA with DDx of metastasis of unknown
primary tumor

Patient was scheduled for USG-guided CNBx on 20/4/65

USG-guided CNBx 20/4/65
Angiogram with embolization
Angiogram with embolization
Angiogram via Co-axial Transarterial angiogram

Branch of hepatic artery

Angiogram with embolization

Hepatic vein

Portal vein Bile duct

Angiogram with embolization

Post-embolization angiogram
Post-embolization USG
Post-embolization USG

Post-emb 1-hr
Post-embolization USG

Post-emb 1-hr
Post-embolization USG

Post-emb 1-hr
CASE 1 : Hepatic artery injury
+ Hospital course
- No abdominal pain, V/S stable
 Hct Plt INR Cr TB DB AST ALT ALP

Pre-op 30.1 179 1.04 3.71 0.72 0.43 174 95 109

POD1 27.9 171 1.09 3.47 0.48 0.47 337 250 120

POD2 25.0 153 3.94

POD3 23.0 126 4.20

POD4 22.6 129 4.04

POD5 3.6

Discharge
CASE 2 : นาย พxx จxx 115621/51
Hepatic artery injury
after liver parenchymal biopsy

+ A 75-year old male patient

+ U/D bed ridden with paralysis from GSW with spinal cord injury
CA prostate, CA sigmoid post sigmoidectomy
AF c RVR on warfarin
T2DM, HTN, DLP
This admission admit since 25/3/65 from AOC with abnormal LFT
Dx : Acute cholangitis with acute cholecystitis
- 25/3 CTWA -> 4-mm distal CBD stone with upstream IHDs dilate
two 1.2 cm gallstone without acute cholecystitis
- 28/3 EUS -> GS, GBW thickening, pericholecystis fluid
Dx acute cholecystitis
- 29/4 ERCP -> 3-mm stone with sludge at CBD
Balloon extraction
- 31/4 ERCP -> Blood clot and infected bile and pus
Dx Hemobillia from post-sphinterotomy bleeding
Plastic stent from right IHD to D2
- 2/4 CTUA : Gangrenous cholecystitis
- 8/4 CT-guided percutaneous cholecystostomy (Due to air-fill GB)

8/4 -> 22/4 Progressive jaundice

Hct Plt INR Cr TB DB AST ALT ALP

25/3 0.6 0.3 310 273 759

29/3 0.8 0.4 130 131 579

31/3 7.0 5.5 184 143 587

8/4 6.8 5.2 111 48 558

22/4 21.8 131k 1.26 0.6 14.9 9.7 372 75 1129

22/4 Set hepatic parenchymal Bx (R/O DILI)

USG-guided CNBx of liver parenchyma 22/4/65
USG-guided CNBx of liver parenchyma 22/4/65
USG-guided CNBx of liver parenchyma 22/4/65
CT whole aorta post-op
CT whole aorta post-op
Hepatic artery embolization 24/4
Hepatic artery embolization 24/4
AP shunt

No active contrast extravasation or pseudoaneurysm

Hepatic artery embolization 24/4 Post-embolization angiogram

Shunt disappeared
CASE 2 : Hepatic artery injury
+ Hospital course
- Clinical stable, wean off Levophed
 Hct Plt INR Cr TB DB AST ALT ALP

22/4 21.8 131 1.26 14.9 9.7 372 75 1129

23/4 19.8 101 1.39 13.7 10.3 392 82 760

PRC 1u
24/4 20.1 123 1.24 13.0 9.8 417 93 765
Point of learning
- Patient preparation and planning
- Identify patient with high risk of
bleeding
- Early detection and management
- Hope for the best and be
prepared for the worst
Hepatic artery injury after biopsy
+ 30 studies, published between 2010 and 2020, n=64,356
+ Major bleeding = 0.48%
+ Risk factor associated with major bleeding
- Decrease population age (P < 0.01) (16x or ped population)
- Poor coagulation profile (Plt, INR)
- Sedation
+ 807 patients, 834 procedures
+ 45 patients with bleeding
18 years

60,000

1.8
 Clinical imaging (2016)

+ 2180 patients , 2335 targeted liver biopsies in tertiary center

+ 0.5% bleeding requiring embolization (12/2335)
+ Positive angiograms findings 11/12 (92%)
- Arteriovenous fistula (5/12)
- Pseudoaneurysm (2/12)
- Extravasation or blush (6/12)
- Negative angiogram (1/12)
 Clinical imaging (2016)

+ 100% Technical success after embolization managed with

embolization
+ 83% Clinical success
+ 17% Complication (2/12)
- Cholecystisis
- Hepatic infarction
Thank you