case_images: PMC10684257_01
case_images: CT abdomen demonstrating pseudoaneurysm of accessory right hepatic artery with surrounding pancreatic pseudocyst.
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case_images: F1
case_images: Four days after admission, a computer tomography (CT) liver (triple phase) demonstrated a large pancreatic head pseudocyst (Fig. 1) - which seemed to have been obscured by bowel gas on the initial ultrasound examination.
case_images: Magnetic resonance cholangiopancreatography demonstrating extrinsic compression on the common bile duct.
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case_images: F2
case_images: This was confirmed on subsequent magnetic resonance cholangiopancreatography, with no intrinsic filling defect (Fig. 2, 3).
case_images: Magnetic resonance cholangiopancreatography. T2w axial image demonstrating extrinsic compression on the common bile duct from the pancreatic head pseudocyst and associated right accessory hepatic pseudoaneurysm.
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case_images: F3
case_images: This was confirmed on subsequent magnetic resonance cholangiopancreatography, with no intrinsic filling defect (Fig. 2, 3).
case_images: CT thorax. Coronal reformat demonstrating an obstructing right lower endobronchial mass.
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case_images: F4
case_images: The initial CT abdomen/pelvis also showed a right lower lobe lung mass (Fig. 4) which was later diagnosed as a lung neuroendocrine tumour following EBUS biopsy.
case_images: Subsequent arterial phase CT demonstrating extension of accessory right hepatic artery pseudoaneurysm into the pancreatic pseudocyst.
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case_images: F5
case_images: CT was performed demonstrating enlargement of the accessory right hepatic artery pseudoaneurysm into the adjacent pseudocyst (now measuring 5.9 x 5.4 x 4.6 cm) (Fig. 5). Compression on the CBD was now causing intra- and extrahepatic biliary tree dilatation (Fig. 6).
case_images: Subsequent CT which demonstrating intrahepatic biliary dilatation.
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case_images: F6
case_images: CT was performed demonstrating enlargement of the accessory right hepatic artery pseudoaneurysm into the adjacent pseudocyst (now measuring 5.9 x 5.4 x 4.6 cm) (Fig. 5). Compression on the CBD was now causing intra- and extrahepatic biliary tree dilatation (Fig. 6).
case_images: Angiogram of right accessory hepatic artery with non-expanded stent in position. Contrast was injected through the sheath which demonstrated filling of the pseudoaneurysm sac.
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case_images: F7
case_images: A superior mesenteric artery angiogram demonstrated the filling pseudoaneurysm (Fig. 7).
case_images: Final digital subtraction angiogram following exclusion of the pseudoaneurysm with the stent graft. There is a degree of vasospasm distal to the stent graft.
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case_images: F8
case_images: This was successful with no further filling of the pseudoaneurysm on subsequent angiogram (Fig. 8).
case_images: Percutaneous transhepatic cholangiogram and insertion of an internal-external drain.
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case_images: F9
case_images: The CBD narrowing was crossed, with ease and an internal-external drain was inserted (Fig. 9).
case_images: Contrast-enhanced CT abdomen 5 days following the exclusion of the pseudoaneurysm.
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case_images: F10
case_images: The CT also showed that the VBX stent was patent and had successfully excluded the pseudoaneurysm (Fig. 10).
case_images: Contrast-enhanced CT abdomen 4 weeks following the exclusion of the pseudoaneurysm. The stent graft remained patent, and there was an interval reduction in size of the pseudoaneurysm.
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case_images: F11
case_images: This was demonstrated to still be patent 4 weeks following the procedure with resultant reduction in size of the pseudoaneurysm (Fig. 11).
case_images: Subsequent cholangiogram and internalisation with deployment of a retrievable common bile duct stent.
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case_images: F12
case_images: The internal-external drain was removed under fluoroscopy, and a 7F plastic CBD stent was inserted (to be retrieved endoscopically in due course) (Fig. 12).