A 60-year-old female with a transhepatic biliary abscess drainage catheter presented with spontaneous bloody output from her catheter. The patient had a history of a remote laparoscopic cholecystectomy which was com- plicated by biliary duct injury and proper hepatic artery ligation. This resulted in substantial hepatic infarction requiring a left hepatectomy and hepaticojejunostomy. The patient also developed a biliary-cutaneous fistula. One month prior to presentation, a dilated and infected peripheral right hepatic duct branch was treated with a 14 Fr percutaneous drainage catheter through the fistula tract (Figure 1). It was through this catheter that the pa-

tient began having pulsatile bloody discharge, and there was concern that the drain had eroded into an adjacent hepatic artery branch. On presentation, the patient was hemodynamically stable and afebrile. She had a normal platelet count and an elevated INR of 1.5.

Review of an angiogram done at an outside facility uncovered a 6 mm hepatic arterial pseudoaneurysm in- volving a branch distal to the ligated proper hepatic artery, and filling via small collaterals. The jailed pseudoa- neurysm was identified coming off of a branch from the right hepatic artery adjacent to the drainage catheter. A repeat angiogram at our institution demonstrated that the collaterals could not provide arterial access to the pseudoaneurysm (Figure 2).

At this point, the 5 French angiographic catheter and sheath were left in the patient and attached to a saline drip. The patient was taken to CT where percutaneous CT guided direct puncture of the pseudoaneurysm and thrombin injection was attempted with opacification of the pseudoaneurysm using the transarterial catheter (Figure 3). Two hundred units of thrombin were injected into the pseudoaneurysm after documentation of blood return from the needle. The patient returned to the angiography suite; however, a repeat angiogram showed con- tinued perfusion of the pseudoaneurysm.

A second attempt was made to treat the pseudoaneurysm percutaneously under fluoroscopic guidance (Figure 4). A 20-gauge Chiba needle was triangulated into the pseudoaneurysm with intermittent opacification via the transarterial catheter. 500 units of thrombin were injected after confirmation of blood return. Repeat angiogra- phy showed no further filling of the pseudoaneurysm with preservation of distal branches. No intravasation was seen when injecting the drainage catheter. Repeat angiography with the drainage catheter withdrawn over a wire confirmed successful occlusion of the pseudoaneurysm. To prevent further erosion of the drainage catheter into the hepatic vasculature, the 14 Fr multipurpose drainage catheter was exchanged for a smaller profile 10 Fr Dawson Mueller drain. The patient tolerated the procedure well. Her only complication was acute kidney injury with her creatinine rising to 1.8 on post-operative day one and returning to baseline the following day. No fur- ther bleeding was seen from the biliary drain and the patient was discharged on post-operative day 4.

Hepatic artery pseudoaneurysm is a rare complication of liver directed procedures. Most cases occur from liver transplantation with an incidence up to 1.3% [1] . Intrahepatic pseudoaneurysms tend to result from trauma, ia- trogenic or otherwise [2] [3] . In this patient, the cause was most likely a combination of the drainage catheter placement and recent infection.

Several strategies for treatment of pseudoaneurysms have been described [4] [5] . Options for visceral pseu- doaneurysm treatment include exclusion with a covered stent or embolization with coils or liquid embolic agents such as N-butyl cyanoacrylate or Onyx. Iatrogenic femoral artery pseudoaneurysms are commonly treated with ultrasound guided direct thrombin injection and have good results [6] . Cope described successful percutaneous thrombin injection into a true hepatic artery aneurysm in 1986 [2] . More recently, multiple cases have been pub- lished in which intrahepatic pseudoaneurysms were treated with percutaneous thrombin injection [3] [7] [8] .

When the pseudoaneurysm is large and easily localized with ultrasound, one may proceed directly to percutane- ous thrombin injection; however, smaller pseudoaneurysms may require an angiogram to localize for transar- terial treatment. In the case presented, the ligated proper hepatic artery precluded endovascular therapy, and the pseudoaneurysm was too small to see by US, leading to the combined approach with transarterial localization and percutaneous thrombin injection.

CT and ultrasound are most commonly used to guide percutaneous thrombin injections [3] [7] [8] . We initial- ly attempted a CT guided approach but saw persistent flow in the pseudoaneurysm on the post-procedure angiogram. Although blood return was present with the needle in the anticipated location within the pseudoaneurysm, the lesion was small enough even to make localization by CT difficult, and the needle position very well might have changed with manipulation prior to thrombin injection. With the patient on the fluoroscopy table, we were

able to triangulate the position of the pseudoaneurysm using a combination of orthogonal-view angiograms. The pseudoaneurysm was successfully injected and thrombosed with no further bleeding and with preservation of the distal branch vessels.

To our knowledge, no cases of combined angiography and fluoroscopy-guided percutaneous thrombin injec- tion have been published. There are several advantages to this approach. The procedure is readily done on the fluoroscopy table without the need for new equipment. There is a smooth transition from angiogram to percuta- neous localization and back to angiogram. Smaller lesions are better visualized on angiogram, especially when they are adjacent to drainage catheters or other equipment which may cause significant artifact on ultrasound. Lastly, confirming occlusion of the pseudoaneurysm by removing the drainage catheter over a wire and testing angiographically could be performed readily.

Combined angiographic and fluoroscopic guided percutaneous thrombin injection of intrahepatic pseudoa- neurysms can be a valuable treatment approach, particularly when other methods are not feasible or have failed.