A rare and fatal injury to the retrohepatic inferior vena cava following percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage (PTBD) is a widely utilized procedure for managing biliary obstructions, particularly in patients with unresectable pancreatic cancer. While generally effective, PTBD carries a risk of complications, including hemobilia, intra-abdominal hemorrhage, catheter-related issues, and, rarely, vascular injuries. We present the case of a 90-year-old woman with pancreatic cancer who underwent PTBD for biliary obstruction. Shortly after the procedure, she developed hypovolemic shock and succumbed within hours. A forensic autopsy revealed a massive hemoperitoneum (2.5 L) resulting from a rupture of the inferior vena cava (IVC), an exceedingly rare complication of PTBD. To our knowledge, this is the first reported case of an IVC rupture directly associated with PTBD. This case underscores the critical importance of operator expertise and meticulous technique during PTBD, as well as the need for heightened awareness of potential, albeit rare, vascular complications. It also highlights the role of autopsy in elucidating unexpected causes of death and in assessing procedural outcomes.