Cystic Artery Pseudoaneurysm: Current Review of Aetiology, Presentation, and Management

Abstract

Background. Cystic artery pseudoaneurysms are rare. Most commonly, they occur secondary to acute cholecystitis or after a cholecystectomy. Complications include haemobilia, biliary obstruction, and haemorrhage. Given the rarity and associated morbidity, a high index of suspicion is required. This article reviews the current literature on cystic artery pseudoaneurysms to investigate its aetiology, clinical presentation, and management options. Methods. A broad search of the Medline and PubMed databases was carried through. All peer reviewed literatures published in the English language between 1991 and 2020 with keywords “cystic” and “artery” and “pseudoaneurysm” in the title were selected for review. No further exclusion criteria; all studies yielded from the search were included in the results of this review. Additionally, we present a case of cystic artery pseudoaneurysm treated at our centre and included this in our analysis. Results. Sixty-seven case reports were found between 1991 and 2020. Aetiologies: Aetiology of cystic artery pseudoaneurysm was found to be cholecystitis in 41 instances (61.2%), cholecystectomy in 18 instances (26.8%), idiopathic in 6 instances (8.9%) cholelithiasis in 1 instance (1.5%), and pancreatitis in 1 instance (1.5%). Complications: Fifty-two cases were complicated by haemobilia (77.6%), 36 by anaemia (53.7%), 25 by biliary obstruction (37.3%), 13 by haemodynamic shock (19.4%), 9 by haemoperitoneum (13.4%), and 6 by contained rupture (8.9%). Most commonly, patients had two or more of these complications. Management: Forty-four patients were managed with endovascular embolisation (65.7%), 21 with endoscopic intervention (31.3%), 18 with open cholecystectomy (26.9%), 13 with laparoscopic cholecystectomy (19.4%), and 6 with pseudoaneurysm ligation (9%). Delayed presentation postcholecystectomy ranged from 8 days to 3 years. Conclusions. Cystic artery pseudoaneurysms are rare complications of a common operation. The most common clinical presentation is haemobilia, which can be difficult to diagnose clinically. A high index of suspicion and prompt investigation with targeted imaging and intervention is required. This is especially pertinent in gastrointestinal bleeding postlaparoscopic cholecystectomy as a missed diagnosis could cause significant morbidity.