S3598 Biliary Complications Due To Stent-Assisted Coil Embolization of a Portal Vein Aneurysm

Introduction: Portal vein aneurysm (PVA) is a rare entity with no clear consensus on the management of enlarging aneurysms. We describe a patient with an idiopathic PVA who underwent stent-assisted coil embolization complicated by biliary obstruction. Case Description/Methods: A 53-year-old woman with coronary artery disease and myelodysplastic syndrome presented for asymptomatic enlarging PVA. Her PVA was previously monitored for 15 years with surveillance imaging, but recent computed tomography angiography showed significant enlargement from an original diameter of 2.3 cm to 5.2 cm by 6.4 cm along with new cirrhosis. Given the rapid enlargement, interventional radiology performed a transhepatic coil embolization of the PVA. Two weeks later, the patient presented with new painless jaundice and pruritus. Lab studies showed total bilirubin of 32.9 mg/dL (direct bilirubin >20 mg/dL), ALP 2,675 U/L, ALT 152 U/L, and AST 128 U/L from previously normal baseline values. Imaging (ultrasound, computed tomography, and magnetic resonance imaging) revealed no evidence of biliary obstruction, and serologic workup and medication review for other etiologies of liver injury were negative. However, the suspicion for an obstructive process remained high so endoscopic ultrasound (EUS) guided liver biopsy and endoscopic retrograde cholangiopancreatography (ERCP) were performed. The liver biopsy revealed mild steatosis without evidence of cirrhosis. ERCP revealed narrowing of the common bile duct from presumed extrinsic compression due to the recently placed portal vein coils and subsequent bile leak. A biliary sphincterotomy was performed and a plastic stent was placed with rapid improvement in the patient’s cholestasis—lab studies obtained 1 week later noted total bilirubin 3.6 mg/dL, ALP 2138 U/L, ALT 47 U/L, and AST 32 U/L. Discussion: PVA is a focal portal venous dilation exceeding either 1.5 cm in normal livers or 1.9 cm in cirrhotic livers. They are rare, with fewer than 200 cases reported in the literature, and thus their management is non-standardized. Current guidelines recommend surgical intervention for PVAs with thrombosis or symptoms, while data on endovascular repair are limited. Our patient underwent stent-assisted coil embolization and later developed cholestatic liver injury. This case illustrates how endovascular PVA repair can cause extrinsic biliary obstruction even without biliary dilation on imaging, highlighting the need for a broad differential for post-procedural liver injury and awareness of this rare complication.