A 59-year-old man who had received liver RF ablation 11 times previously was admitted to receive further liver RF ablation for treatment of a recurrent hepatic carcinoma. Liver RF ablation was performed in Jan 2011. He had hepatitis B-related liver cirrhosis. Child-Pugh score was class A. Coagulability was within the normal range (international normalized ratio, 1.06). At the time of liver RF ablation, 5 hepatic lesions were found. The α-fetoprotein level was elevated to 133 ng/mL. First we ablated 4 peripheral lesions, and the lesion located in caudate lobe was ablated finally (Figure ). Liver RF ablation was done under laparotomy. Cool-tip RF electrodes (Radionics, Burlington, MA, United States) were placed in three different sites of the tumor. Then RF energy was applied for 15 min to each site. An abdominal tube was placed under the left hepatic lobe. Near-fatal bleeding developed 1 wk after RF ablation.
Figure 1 The exposure and radiofrequency ablation of the lesion in the caudate lobe under laparotomy. A: The tumor found in the caudate lobe. The arrow indicates the lesion; B: The largest tumor in the Caudate lobe measuring 4 cm was treated with radiofrequency (more ...)
Vital signs were unstable; the patient presented with acute hemorrhagic shock immediately. The hemoglobin level decreased by 6 g/dL and the patient was transferred immediately to the operating room. Explorative laparotomy was carried out. More than 4000 mL blood was lost in the abdominal cavity, active bleeding from the caudate lobe was identified. A hepatic artery pseudoaneurysm measuring 15 mm maximum in diameter was observed in the hematoma using intra-operative ultrasound (Figure ). The bleeding site was first sutured and then packed with ribbon gauze for hemostasis, vital signs returned to normal and the patient was moved to intensive care. Eleven hours later, fresh blood appeared in the abdominal tube, the drainage was more than 100 mL/h, heart rate increased subsequently, the patient was moved to the angiographic suite.
Introperative ultrosound study showed a hepatic artery pseudoaneurysm within the hematoma.
Angiography revealed bleeding from the pseudoaneurysm in a branch of the left hepatic artery (Figure ). A microcatheter (2.0 Fr, Progreat; Terumo Corp, Tokyo) was advanced into the pseudoaneurysm through a 5-Fr catheter. Subsequently, five microcoils (Tornado Embolization Microcoils; Cook Medical Inc, Bloomington, IN) were deployed into and proximal to the pseudoaneurysm through the left hepatic artery. Immediately after coil embolization, the pseudoaneurysm was excluded successfully (Figure ). Other than a little bile leakage, the patient recovered smoothly after left hepatic arterial embolization. A contrast enhanced computed tomography (CT) study acquired 1 month later revealed that the pseudoaneurysm had disappeared. No tumor enhancement was apparent in the ablated site. The coils used for embolization were visualized (Figure ). The serum a-fetoprotein level remained within the normal range (6 ng/mL).
Figure 3 Hepatic angiography before and after coil embolization. A: Hepatic angiography revealed a pseudoaneurysm in the lower left hepatic artery; B; Hepatic angiography immediately after coil embolization. Coils were placed using a 2.1 F microcatheter into and (more ...)
Computed tomography scan acquired 1 mo later. The image revealed that the pseudoaneurysm had disappeared. No tumor enhancement was apparent at the ablated site. The coils used for embolization were visualized.