Conservative Management With Tranexamic Acid for Intrahepatic Pseudoaneurysm After Unsuccessful Biliary Drainage in a Patient on Apixaban

Conservative management with tranexamic acid (TXA) is known in difficult-to-access pseudoaneurysms, including those of the pulmonary artery, and its broad efficacy is seen in hemorrhagic pathologies such as subarachnoid hemorrhage. We present the case of a 90-year-old woman with paroxysmal atrial fibrillation on apixaban, remote cholecystectomy, and multiple comorbidities (including hypothyroidism, interstitial lung disease, and asthma) who was admitted for right upper quadrant pain, nausea, and laboratory evidence of cholestasis (total bilirubin 3.0 mg/dL, aspartate aminotransferase 250 U/L). Computed tomography was suggestive of choledocholithiasis, and gastroenterology recommended briefly holding apixaban before endoscopic retrograde cholangiopancreatography (ERCP). On hospital day 3, ERCP was abandoned because of an upper esophageal sphincter narrowing and Zenker’s diverticulum. Interventional radiology then performed a percutaneous transhepatic cholangiography with a 22-gauge Chiba needle, but nondilated intrahepatic ducts prevented drain placement. Ultimately, a laparoscopic-assisted ERCP achieved successful common bile duct stone extraction. Postprocedurally, the patient’s hemoglobin declined from 13.6 to 9.4 g/dL (without transfusions), and abdominal imaging identified a 1.8-cm intrahepatic pseudoaneurysm plus a 4.1-cm peripancreatic hematoma. Diagnostic angiography demonstrated delayed pseudoaneurysm filling without a definable feeding artery suitable for embolization. Given the small lesion and occult arterial source, we administered oral TXA 1,000 mg three times daily to promote thrombosis. Within 48 hours, hemoglobin stabilized around 8.8 g/dL, and repeat CT revealed spontaneous pseudoaneurysm thrombosis. The patient was discharged uneventfully with stable hemoglobin and had no pseudoaneurysm reaccumulation at short-term follow-up. Should TXA have failed, we had discussed a potential percutaneous thrombin injection, which has shown success for endovascularly inaccessible hepatic pseudoaneurysms. This case underscores the risk of iatrogenic bleeding in patients on direct oral anticoagulants who require multiple biliary interventions and highlights how a short course of TXA can be a practical alternative when standard embolization is not feasible.