Ultraselective N-Butyl Cyanoacrylate Embolization of an Arteriobiliary Fistula After Transjugular Liver Biopsy With Preservation of Parent Arterial Flow

Hemobilia is a rare but potentially life-threatening complication of transjugular liver biopsy (TJLB).An arteriobiliary fistula associated with a hepatic arterial pseudoaneurysm may require prompt endovascular treatment.We report the case of a 17-year-old male who underwent TJLB to evaluate liver dysfunction in the presence of coagulopathy.Two days later, he developed abdominal pain and hyperbilirubinemia.Although his hemoglobin level was initially unchanged, progressive anemia subsequently developed despite blood transfusion.Computed tomography revealed a 3-mm pseudoaneurysm adjacent to the posterior sectoral branch of the right hepatic artery and findings suggestive of hemobilia.Five days after TJLB, ultraselective angiography confirmed communication between the pseudoaneurysm and the bile duct.Subsequent ultraselective embolization with a mixture of N-butyl cyanoacrylate (NBCA) and Lipiodol achieved complete occlusion of the fistula while preserving posterior sectoral arterial flow.Minimal migration of the NBCA-Lipiodol cast into a peripheral bile duct occurred during embolization.Abdominal pain resolved, and bilirubin levels returned to baseline within five days.The radiopaque component of the migrated cast was no longer visible on follow-up CT, and subsequent magnetic resonance cholangiopancreatography showed no intrabiliary filling defects.No clinically significant biliary complications were observed during 28 months of follow-up.This case illustrates the feasibility of ultraselective NBCA embolization when coil isolation is limited by vascular anatomy, while emphasizing the risk of intrabiliary migration and the need for followup.