Vascular complications in percutaneous biliary interventions

Table 2 Steps and management of arterial and venous haemobilia

Step	Arterial haemobilia (high-flow)	Venous haemobilia (low-flow/bilio-venous)
Clinical presentation	Hemodynamic instability, hematemesis, rapid hemoglobin drop, pulsatile blood in bag	Dark blood-tinged bile, melena, insidious hemoglobin drop, often stable vitals
Initial action	Emergency stabilization: IV fluids, blood transfusion, urgent interventional radiology consult	Conservative: Saline flush of catheter, monitor vitals and hemoglobin
Diagnostics	Mandatory computed tomography angiography followed by urgent digital subtraction angiography	“Pull-back” cholangiogram; computed tomography angiography to identify the tract; percutaneous
Primary treatment	Selective transcatheter arterial embolization	Catheter upsizing: Replace with a larger bore drain for tamponade
Technical strategy	“Back to front door” (sandwich)	Portal covered stenting (in high flux fistulas)
Alternative	Covered stents if main hepatic artery branches are involved	Temporary clamping (24-48 hours) or percutaneous tract embolization
Resolution	Confirm cessation of bleeding via digital subtraction angiography and clinical monitoring	Maturation/scarring of the tract; resolution of “haemobilia”